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Canadian Physical
Activity Guidelines for
Adults with MS Presented by Susan Ehler BScPT
What are the guidelines Guidelines established for adults ages 18-64 with minimal
to moderate disability from RR or progressive forms of MS
Guidance for individuals with MS as well as health care
professionals working with them
What will the guidelines tell
me How a person with MS can add safe appropriate and
effective physical activity into their day
A reference for appropriate physical activity levels
Minimum freq intensity duration and type of physical
activity needed for improved fitness for adults with MS
How will the guidelines help
Following the Guidelines can improve fitness related to
aerobic endurance and muscle strength
Fitness is especially important for people with MS as rates
of inactivity and deconditioning are high
May reduce fatigue improve mobility and enhance quality
of life
What if I canrsquot meet the
Guidelines For those currently inactive activities performed at a
lower level can still result in benefits
Gradual increase toward recommended Guidelines
Are there any risks No scientific evidence that following these Guidelines will
result in relapse of MS symptoms or worsen fatigue or
health related quality of life
Potential benefits exceed potential risks associated with
physical activity
Who created the Guidelines International standard for health guideline development
Researchers reviewed all literature
Consensus panel met to review research
Consensus panel developed Guidelines based on
research
Guidelines circulated to experts for review and
feedback
Guidelines revised based on feedback
Who is releasing the
Guidelines Canadian Society of Exercise Physiology
MS Society of Canada
ParticipACTION
Canadian Institutes of Health Research
Getting started Setting goals
Studies show that people who set challenging but achievable goals are more likely to be active
Making an action plan
Include what where when how long and intensity level
How to set exercise goals 1) Establish what you can do now
2) Set a goal for this week
3) Set a goal for this month
4) Check in at the end of each week to see how you are
doing
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
What are the guidelines Guidelines established for adults ages 18-64 with minimal
to moderate disability from RR or progressive forms of MS
Guidance for individuals with MS as well as health care
professionals working with them
What will the guidelines tell
me How a person with MS can add safe appropriate and
effective physical activity into their day
A reference for appropriate physical activity levels
Minimum freq intensity duration and type of physical
activity needed for improved fitness for adults with MS
How will the guidelines help
Following the Guidelines can improve fitness related to
aerobic endurance and muscle strength
Fitness is especially important for people with MS as rates
of inactivity and deconditioning are high
May reduce fatigue improve mobility and enhance quality
of life
What if I canrsquot meet the
Guidelines For those currently inactive activities performed at a
lower level can still result in benefits
Gradual increase toward recommended Guidelines
Are there any risks No scientific evidence that following these Guidelines will
result in relapse of MS symptoms or worsen fatigue or
health related quality of life
Potential benefits exceed potential risks associated with
physical activity
Who created the Guidelines International standard for health guideline development
Researchers reviewed all literature
Consensus panel met to review research
Consensus panel developed Guidelines based on
research
Guidelines circulated to experts for review and
feedback
Guidelines revised based on feedback
Who is releasing the
Guidelines Canadian Society of Exercise Physiology
MS Society of Canada
ParticipACTION
Canadian Institutes of Health Research
Getting started Setting goals
Studies show that people who set challenging but achievable goals are more likely to be active
Making an action plan
Include what where when how long and intensity level
How to set exercise goals 1) Establish what you can do now
2) Set a goal for this week
3) Set a goal for this month
4) Check in at the end of each week to see how you are
doing
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
What will the guidelines tell
me How a person with MS can add safe appropriate and
effective physical activity into their day
A reference for appropriate physical activity levels
Minimum freq intensity duration and type of physical
activity needed for improved fitness for adults with MS
How will the guidelines help
Following the Guidelines can improve fitness related to
aerobic endurance and muscle strength
Fitness is especially important for people with MS as rates
of inactivity and deconditioning are high
May reduce fatigue improve mobility and enhance quality
of life
What if I canrsquot meet the
Guidelines For those currently inactive activities performed at a
lower level can still result in benefits
Gradual increase toward recommended Guidelines
Are there any risks No scientific evidence that following these Guidelines will
result in relapse of MS symptoms or worsen fatigue or
health related quality of life
Potential benefits exceed potential risks associated with
physical activity
Who created the Guidelines International standard for health guideline development
Researchers reviewed all literature
Consensus panel met to review research
Consensus panel developed Guidelines based on
research
Guidelines circulated to experts for review and
feedback
Guidelines revised based on feedback
Who is releasing the
Guidelines Canadian Society of Exercise Physiology
MS Society of Canada
ParticipACTION
Canadian Institutes of Health Research
Getting started Setting goals
Studies show that people who set challenging but achievable goals are more likely to be active
Making an action plan
Include what where when how long and intensity level
How to set exercise goals 1) Establish what you can do now
2) Set a goal for this week
3) Set a goal for this month
4) Check in at the end of each week to see how you are
doing
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
How will the guidelines help
Following the Guidelines can improve fitness related to
aerobic endurance and muscle strength
Fitness is especially important for people with MS as rates
of inactivity and deconditioning are high
May reduce fatigue improve mobility and enhance quality
of life
What if I canrsquot meet the
Guidelines For those currently inactive activities performed at a
lower level can still result in benefits
Gradual increase toward recommended Guidelines
Are there any risks No scientific evidence that following these Guidelines will
result in relapse of MS symptoms or worsen fatigue or
health related quality of life
Potential benefits exceed potential risks associated with
physical activity
Who created the Guidelines International standard for health guideline development
Researchers reviewed all literature
Consensus panel met to review research
Consensus panel developed Guidelines based on
research
Guidelines circulated to experts for review and
feedback
Guidelines revised based on feedback
Who is releasing the
Guidelines Canadian Society of Exercise Physiology
MS Society of Canada
ParticipACTION
Canadian Institutes of Health Research
Getting started Setting goals
Studies show that people who set challenging but achievable goals are more likely to be active
Making an action plan
Include what where when how long and intensity level
How to set exercise goals 1) Establish what you can do now
2) Set a goal for this week
3) Set a goal for this month
4) Check in at the end of each week to see how you are
doing
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
What if I canrsquot meet the
Guidelines For those currently inactive activities performed at a
lower level can still result in benefits
Gradual increase toward recommended Guidelines
Are there any risks No scientific evidence that following these Guidelines will
result in relapse of MS symptoms or worsen fatigue or
health related quality of life
Potential benefits exceed potential risks associated with
physical activity
Who created the Guidelines International standard for health guideline development
Researchers reviewed all literature
Consensus panel met to review research
Consensus panel developed Guidelines based on
research
Guidelines circulated to experts for review and
feedback
Guidelines revised based on feedback
Who is releasing the
Guidelines Canadian Society of Exercise Physiology
MS Society of Canada
ParticipACTION
Canadian Institutes of Health Research
Getting started Setting goals
Studies show that people who set challenging but achievable goals are more likely to be active
Making an action plan
Include what where when how long and intensity level
How to set exercise goals 1) Establish what you can do now
2) Set a goal for this week
3) Set a goal for this month
4) Check in at the end of each week to see how you are
doing
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Are there any risks No scientific evidence that following these Guidelines will
result in relapse of MS symptoms or worsen fatigue or
health related quality of life
Potential benefits exceed potential risks associated with
physical activity
Who created the Guidelines International standard for health guideline development
Researchers reviewed all literature
Consensus panel met to review research
Consensus panel developed Guidelines based on
research
Guidelines circulated to experts for review and
feedback
Guidelines revised based on feedback
Who is releasing the
Guidelines Canadian Society of Exercise Physiology
MS Society of Canada
ParticipACTION
Canadian Institutes of Health Research
Getting started Setting goals
Studies show that people who set challenging but achievable goals are more likely to be active
Making an action plan
Include what where when how long and intensity level
How to set exercise goals 1) Establish what you can do now
2) Set a goal for this week
3) Set a goal for this month
4) Check in at the end of each week to see how you are
doing
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Who created the Guidelines International standard for health guideline development
Researchers reviewed all literature
Consensus panel met to review research
Consensus panel developed Guidelines based on
research
Guidelines circulated to experts for review and
feedback
Guidelines revised based on feedback
Who is releasing the
Guidelines Canadian Society of Exercise Physiology
MS Society of Canada
ParticipACTION
Canadian Institutes of Health Research
Getting started Setting goals
Studies show that people who set challenging but achievable goals are more likely to be active
Making an action plan
Include what where when how long and intensity level
How to set exercise goals 1) Establish what you can do now
2) Set a goal for this week
3) Set a goal for this month
4) Check in at the end of each week to see how you are
doing
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Who is releasing the
Guidelines Canadian Society of Exercise Physiology
MS Society of Canada
ParticipACTION
Canadian Institutes of Health Research
Getting started Setting goals
Studies show that people who set challenging but achievable goals are more likely to be active
Making an action plan
Include what where when how long and intensity level
How to set exercise goals 1) Establish what you can do now
2) Set a goal for this week
3) Set a goal for this month
4) Check in at the end of each week to see how you are
doing
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Getting started Setting goals
Studies show that people who set challenging but achievable goals are more likely to be active
Making an action plan
Include what where when how long and intensity level
How to set exercise goals 1) Establish what you can do now
2) Set a goal for this week
3) Set a goal for this month
4) Check in at the end of each week to see how you are
doing
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
How to set exercise goals 1) Establish what you can do now
2) Set a goal for this week
3) Set a goal for this month
4) Check in at the end of each week to see how you are
doing
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Tips to achieve your goals Be flexible
Be steady
Share your goals
Be aware of your body
Celebrate your success
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Making an action plan What
Where
When
How long
Intensity level
Back up plan
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Itrsquos all about you Your ability
Do what you can towards meeting the guidelines
Your way
Pick moderate intensity activities that feel good and that
you enjoy
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
The Guidelines
30 mins aerobic activity 2 timesweek
Strength training exercises for major muscle groups 2
timesweek
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
How hard do I exercise Aerobic activities should be moderate in intensity ndash move
and talk
Strength ndash 2 sets of 10-15 reps for all major muscle
groups
Strength ndash challenging to
finish 2nd set
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
How much rest Aerobic and strength training can be done on the same
day
Avoid strength training the same muscle group 2 days in a
row
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Tips to avoid injury Progress at your own pace
Consult a health professional for activity suggestions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
How do I stay cool Air conditioned spaces on hot humid days
Drink lots of cool water
Use a spray bottle
Consider pool-based activities
Monitor how you are feeling Move to a cool spot and
rest
Cooling equipment such as a vest collar or cuffs
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Activity suggestions Aerobic
Walk or bike
Arm ergometer
Dance
Swim or aqua fitness
Team sports or active family gamesvideo games
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Activity suggestions Strength training
Lift weights ndash free weights or machines
Resistance bands
Body weight ex ndash push ups squats
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Other activities These exercises can help build flexibility balance and body awareness
Tai chi
Yoga
Pilates
These are great activities to do in addition to the activity guidelines
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Exercise and Multiple
Sclerosis
Dr Christine Short
Associate Professor
Dalhousie University Halifax
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Why Exercise
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Whatrsquos the evidence In 1996 the National MS society funded the first study
to look at the affects of exercise on MS Many have
followed
Improved fatigue
Improved walking speed
Improved strength
Improved quality of life
Improved function
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Barriers People with MS can have many barriers to exercising
Weakness
Fatigue
Heat sensitivity
Spasticity
Pain
Transportation
Financial
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Weakness Progressive resistance exercises are the most effective
way to increase muscle strength even in patients with
central nervous system dysfunction
Effective even in profoundly weak muscles in MS
Kraft 1996
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Weakness mimics Opposing spasticity
Progressive weakness with activity
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Weakness Treatment
Progressive resistive exercises (PREs)
Bracing (eg ankle dorsiflexor weakness)
Maximize spasticity management
Nerve stimulation
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Fatigue Most common self identified symptom in MS
77 of patients whit MS
Most Pronounced in the afternoon
Kraft 1986
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Fatigue management Rule out aggravating factors Depression Thyroid dysfunction
Medications Amantidine Modafanil pemoline
Non-pharmacological treatment Cooling Exercise Energy conservation techniques
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Heat sensitivity Exercise in a cool enviornment
Cooling garments
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Spasticity Common in MS
May go unrecognized
Spasticity is different to different people
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Impact of Spasticity
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Impact of Spastic Disorders on Quality of Life
I spasticity all bad
No
Maintains muscle bulk
Mechanical factor in improving venous flow
preventing venous stasis complications (phlebitis and
DVT)
Some individuals use their tone to perform certain
ADLs
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Spasticity treatment
Non-pharmachologic
Therapeutic Exercise
Modalities
Bracing
Positioning Splints
Serial Casting
Seating Systems
ADL and Mobility Equipment
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Non-pharmachologic Exercise
Rosche J Paulus C etal Spinal Cord 1997
Cycling in MS patients and lower extremity spasticity
pre and post EMG showed a definite reduction in motor
neuron excitability post cycling
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Non-pharmachologic
Stretching
Fundamental underpinning of all spasticity
management
Must be done frequently
Inverse relationship between length of muscle
tendonous unit and the stimulus to induce spasticity
Prevents contracture and skin comp
A stretch must be maintained to impact spasticity
Otis JC et Al J pediatr orthopedics 1985
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Non-pharmachologic Strengthening
spasticity inactivity weakness
Exercise must be judicious to avoid
excessive fatigue
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Non-pharmachologic Orthotics
wheelchairs
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Oral Medications
Baclofen
Tizanidine
Gabapentin
Benzodiazepines
Dantrolene
sodium
Clonidine
Cyproheptadine
Cannabinoids
4-aminopyridine
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Botulinum Toxin Produced by the bacterium Clostridium botulinum
Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use
Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)
Conversion ratio 1 Unit BOTOX~3-5 Units Dysport
Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Pre and Post BTXA
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Fampridine (4-Aminopyridine 4-AP)
Freely crosses BBB
Blocks fast-activating voltage-gated K+ channels
Prolongation of action potential
Increased safety factor for firing action potential
Possible enhancement of synaptic transmission
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Without
Fampridine
K+
K+
With Fampridine
Mechanism of Fampridine History of Fampridine-
SR
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
83
348
0
10
20
30
40
50
Placebo (N=72) Fampridine-SR 10mg bid (N=224)
Plt0001
MS-F203 Fampridine-SR Increases
Timed Walk Response
Protocol-Specified Primary Endpoint
Proportion
plusmn 95
Confidence
Limits
Placebo
(N=72)
Fampridine-SR 10 mg
(N=224)
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
MS-F204 Confirms Fampridine-SR
Significantly Increases Timed Walk
Response
Protocol-Specified Primary Endpoint
93
429
0
10
20
30
40
50
60
Placebo (N=118) F-SR 10 mg bid(N=119)
Plt0001
Proportion
plusmn 95
Confidence
Limits
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Pain Presenting sx in 20 prevalence is 50 for moderate
to severe pain
Multiple potential causes
Inflammation
Neuropathic
Upper motor neuron damage
MSK
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Pain Types
PAIN
Neuropathic
Peripheral Central
Nociceptive
Musculoskeletal Visceral
Nicholson BD (2003)
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Pain Treatment Tailor based on most likely cause
MSK pain rx with acetaminophen NSAIDs local injection
physiotherapy and modalities
Neuropathic pain rx with TCAs and other antidepressants
anticonvulsants cannabinoids opioids
Severe cases consider intrathecal baclofen with morphine
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Adaptive Aides
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Adaptive aides Exercise
Equipment Braces
Canes
Crutches
Walkers
Wheelchairs
Adapted exercise equipment
water
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Dictus orthosis
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Exercise equipment
Motomed
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Uppertone Stim bike
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Intimacy
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Community programs AIM
Respiratory Health program
Yoga for persons with disabilities
MS exercise classes
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Breathing Space Yoga amp Wellness Centre
Fully Alive Chair Yoga - 6 week program on Weds
starting May 7 2-3pm
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
No paraplegia in a kayak
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Nutrition and MS Karen Gibson
Clinical Dietitian
Nova Scotia Rehabilitation Center
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
What to believe
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Be Wary
Promises of results
Cure
Magic ingredient
Available only through a site
If It Sounds too Good to be True It Is
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Some common diets suggested for MS
The Swank Diet
Studies were not blind or randomized and participant selection was biased
The MacDougal Diet
Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic
Mind Your Mitochondrial Diet
Testimonial
Requesting money for research
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
What Have I got to Lose $$$
Can interfere with Medication prescribed by your Physician
Can be dangerous
Emotional Cost
The reality is success rates are low for controversial or untested therapies
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
ldquoThis matters to me because over the last 20 years I
have been encouraged to try so many expensive drugs
or treatments I would have done better to have a good
holiday It is hope that makes us grab at straws We
need facts not dreamsrdquo
Rita Baille has multiple sclerosis
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Accurate Information
Dietitianrsquos provide nutrition advice that is
based in science
Science never relies on just one study
Good science takes years
Not all studies are created equal
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
What we know
Nutrition needs of people with MS vary greatly
Age
Height
Weight
Mobility
No single nutrition plan meets the needs of all
individuals with MS
bull Co-Morbidities
bull Bowel and Bladder Issues
bull Swallowing Difficulties
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
A Healthy Diet Promotes Optimal
Health Includes servings from all 4 food groups
Includes a wide variety of foods
Is rich in nutrient dense foods
Includes bright coloured fruits and vegetables
Includes whole grain starches
Lean protein
Oily Fish
Limits total fat intake
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Calcium and Vitamin D
People with MS are at increased risk of falls
People with MS have a higher risk of low bone mineral density
1000-1500mg of calcium a day is recommended to maintain healthy bones
People with MS should supplement their diet with Vitamin D
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Calcium Content of food Food
250 ml glass of milk
1 ounce of hard cheese
frac34 c plain yogurt
frac12 c frozen yogurt
12 cottage cheese
frac34 cup baked beans
frac34 cup tofu
1 tbsp molasses
Calcium content (mg)
300
245
295
110
100
100
250
180
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Vitamin D Food
1 cup of milk
1 large egg yolk
1 tsp margarine
2 frac12 ounces pink salmon
2 frac12 ounces Atlantic salmon
2 frac12 ounces canned Mackerel
Vit D
100
60
25
350-500
180-240
220
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Vitamin D from Sunshine
5-30 minutes of exposure to sunshine between
1000 and 300 at least twice a week to the
facearms legs or back without sunscreen will
usually provide us with enough Vit D
Sunscreen with an SPF of 8 or more will block
UV rays
UVB rays do not penetrate glass
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Vitamin D supplementation
Vitamin D 800-2000 IU
Up to 4000 IU can be taken without risk
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Diet modifications can help manage
symptoms of MS
Weight Management
Bowel and bladder continence
Swallowing difficulties
Skin integrity
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Healthy Eating Start with Canadarsquos Food Guide
Choose a variety of nutritious foods
Donrsquot restrict your diet
Supplement with Vitamin D
MS Society of Canada
Ask for help
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Nutrition and Multiple
Sclerosis Dr Christine Short
Associate Professor
Dalhousie University Halifax
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
The Vitamin D Story
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Why vitamin D The geography of MS
Potent modulator of the immune system
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
The literature Over 100 articles published every year for the last 5
years on Vitamin D in MS
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health
set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease
bull The study was published January 20 2013 in JAMA Neurology
bull 465 people with early-stage MS
bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later
bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume
bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression
bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability
bull These results suggest that vitamin D has a protective effect on the disease process underlying MS
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Vitamin D and MS bull Studies are showing that
bull maintaining adequate levels of vitamin D may have a
protective effect and lower the risk of developing
multiple sclerosis (MS)
bull for people who already have MS vitamin D may lessen
the frequency and severity of their symptoms
bull Lower vitamin D levels found in people with more
severe disease
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
How Much 2000-4000 IU daily
Very large doses of vitamin D over an extended period
can result in toxicity
Signs and symptoms include nausea vomiting
constipation poor appetite weakness and weight loss
In addition vitamin D toxicity can lead to elevated
levels of calcium in your blood which can result in
kidney stones
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Other Vitamins Bitarafan S et al 2014
Our study support that lower magnesium and folate
diets are correlated with higher fatigue scores in MS
patients
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
MS and Osteoporosis
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
DEFINITION
ldquo A disease characterized by low bone mass and
microarchitectural deteriorations of bone tissue leading
to enhanced bone fragility and a consequent increase in
risk of fracturesrdquo
(National Institute of Health consensus conference 1994)
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Risk Factors Genetics (vitamin D receptor
allele)
Early menopause
Small build
Nuliparity
Cigarette smoking
Low calcium intake
Sedentary lifestyle (lack of weight bearing exercise disuse)
Chronic illness (inflammatory arthritis GI disorders)
Certain medications (Corticosteroids anticonvulsants)
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Osteoporosis can be Primary or
Secondary
Any age
Male or female
Corticosteroids
Long-term anticonvulsants
GI disease or procedure
Disuse
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Factors contributing to osteoporosis in the
rehabilitation population
Disuse osteoporosis
Increased bone resorption
Decreased bone production
Immobilization hypercalcemia
Insufficient 25-hydroxywitamin D
Hyperparathyroidism
Concomitant medications and disease
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Multiple Sclerosis Motor disturbances caused by progressive
pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients
Frequent need for steroids in managing relapsing remitting disease
Vitamin D
Khachanova et al 2006
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls
BMD was measured using dual X-ray absorptiometry (DXA)
MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls
BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)
MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml
EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD
There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD
Ozgocmen S et al 2005
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Multiple Sclerosis
Evaluated 38 patients with multiple sclerosis
Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck
17 patients (425) had osteopenia and 15 patients (375) had osteoporosis
Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures
EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine
No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis
Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients
Weinstock-Guttman B 2004
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Bone Health in MS In a large US study examining over 1000000 hip
fractures the prevalence of MS in the population with
hip fracture was greater than twice that predicted and
MS patients suffered an acute fracture at an earlier
age
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Bone Health in Multiple Sclerosis
Treatment
Baseline bone density
Calcium
1000-1200mg per day
Diet +- supplement
Vitamin D
1000 to 2000 IU per day for bone health
Usually need a supplement to achieve this amount
Weight bearing exercise
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions
Conclusions Exercise and healthy diet are essential to good health and
wellbeing in all of us
This becomes even more important for people with chronic conditions like MS
There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs
Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management
Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program
Questions