Multiple sclerosis (MS) is the most common autoimmune disease of the brain and previously thought of as incurable . However, the idea that MS can be hacked and put into remission has recently emerged.
In this post, we review treatments for MS and how they work – both alternative and conventional.
The Wahls Protocol Review
The Wahls Protocol developed by Dr. Terry Wahls involves a modified paleolithic diet with antioxidants, nutritional supplements, stretching, neuromuscular stimulation, and strengthening exercises. The purpose of this regimen is to increase the quality of life and combat fatigue, a disabling symptom of multiple sclerosis .
The purpose of the Wahls Protocol diet is to :
- reduce inflammation
- improve mitochondrial function
- correct nutritional deficiencies that contribute to the disease
- reduce oxidative stress and protect the nerve cells by providing dietary antioxidants
Important nutrients in the Wahls Protocol include vitamin D, calcium, magnesium, omega-3 fatty acids, coenzyme Q, and dietary enzymes .
The Wahls Protocol is categorized into 3 levels – Wahls Diet (allows gluten-free grains and legumes), Wahls Paleo, and Wahls Paleo Plus with varying levels of restrictions. The Wahls Paleo Plus recommends using fats liberally and reducing proteins to enter ketosis.
The following are foods and recommendations related to the Wahls Protocol Diets :
- Green leafy vegetables – recommended 3 servings
- Sulfur-rich vegetables such as cruciferous vegetables, onion-family vegetables, and mushrooms – recommended 3 servings
- Intensely colored fruits or vegetables – recommended 3 servings
- Omega-3 oils – encouraged 2 tablespoons
- Animal protein – encouraged 4 ounces or more
- Organic meats – at least 1 serving per week
- Plant protein – encouraged 4 ounces or more
- Nutritional yeast – encouraged 1 tablespoon
- Alternative types of milk (soy, almond, peanut, rice, and coconut) – encouraged, subjective to individual choice
- Kelp – encouraged ¼ teaspoon
- Green algae – encouraged ¼-1 teaspoon
- Gluten-free starchy vegetables and fruits – allowed only 2 servings per week
- Added fats, including coconut oil, avocados, olive oils, nuts, and seeds
The protocol also recommends eating 2 meals a day and fasting 12 – 16 hours every day (including sleep time).
Is the Wahls Protocol Effective?
In the few studies that are available, this diet seems to have a disease-modifying effect. It not only reduces symptoms but also helps with the regeneration of the destroyed neuronal tissues beyond what conventional treatments could do.
For Dr. Terry Wahls herself, the diet, in combination with exercise and neuromuscular electrical stimulation, reversed most of her MS symptoms [6, 7]. In a short pilot study involving 12 MS patients, the diet, together with exercise, stretching, massage, and meditation, significantly reduced fatigue .
Additional larger and controlled studies would be necessary to demonstrate the safety and effectiveness of this protocol.
Why the Wahl’s Protocol Works: Potential Mechanism
The Wahl’s Protocol is a mild ketogenic diet.
Ketogenic diets have been used to successfully manage many neurological diseases including epilepsy, Alzheimer’s, and Parkinson’s diseases . A ketogenic diet may help with MS by:
- Inhibiting mTOR, thus suppressing Th1 and Th17 dominance, while increasing Treg 
- Reducing glucose metabolism, which protects against glutamate-induced toxicity and oxidative stress in the brain 
- Activating autophagy, which allows for cellular clean up of damaged myelin and neurons 
- Supporting myelination 
- Increasing Sirt1 (important for cognitive function, brain, and synaptic plasticity) and BDNF levels by ketone bodies [13, 14]
This protocol also eliminates common inflammatory foods.
The Wahls Protocol eliminates gluten, dairy, and legumes, which are some of the most inflammatory foods for people with autoimmunity.
By eliminating gluten, the diet reduces leaky gut and leaky brain through the zonulin pathway.
Dairy protein butyrophilin is similar to proteins on myelin, which could trigger MS .
Legumes contain some of the most harmful lectins, but it is allowed on the Wahls protocol if prepared properly to reduce lectins and other harmful substances.
Wahls Protocol is a micronutrient-dense diet that supports the mitochondria.
The basis of the Wahls Protocol is that it supplies a lot of nutrients and antioxidants for the mitochondria.
The mitochondrial enzyme that consumes oxygen (complex IV) can be blocked by nitric oxide, which is generated in high levels around active MS lesions [16, 17]. This can cause symptoms of low oxygen, increased oxidative stress, and subsequently brain degeneration.
The mitochondria, therefore, is a potential therapeutic target for MS treatment. However, a challenge in devising such therapy is that it is difficult to ensure that these antioxidants enter the brain, the affected cells, and the mitochondria . Additional studies would be necessary to test whether this diet improves MS outcomes mainly through supporting mitochondrial function.
This protocol also addresses other factors, not only diet.
Management of autoimmune diseases typically involves much more than diet alone.
The Wahls Protocol also addresses these other factors by recommending:
- Exercise therapy, which helps stimulate neuronal regeneration by increasing BDNF and NGF
- Neuromuscular stimulation, which helps reduces spasms and muscle wasting
- Meditation and stress management, which reduces inflammation
- Reducing toxic load, which is a risk factor and may cause MS
The Swank Diet Review
The Swank diet was developed in the 50s before multiple sclerosis was well understood as an autoimmune disease. Interestingly, the term “autoimmune” was not used in any of Dr. Swank’s published reports, including ones that were published as late as in the 90s.
This diet is based on the (incorrect or incomplete) assumption that saturated fat consumption caused MS because the incidence of MS seemed to be higher in regions and during times of higher fat consumption . The author, however, was aware that saturated fats or fat consumption may not be the sole cause of MS.
The Swank diet, developed by Dr. Roy Swank, consists of eating foods with very low saturated fat (less than 20 grams a day). Butterfats and hydrogenated oils are eliminated from this diet. The diet contains lean meats such as fish, seafood, skinless turkey, and the white meat of the chicken. These meats are supplemented with skimmed milk, vegetables, cereal, nuts, and one egg a day .
The Swank diet diminished the frequency of attacks and the severity of MS over the course of 50 years .
However, so far only one cohort study has examined the relations between fat consumption and MS risks. This study reported that low consumption of omega-3 fatty acids, but not the high consumption of saturated or animal fats, were associated with increased MS risks .
A recent randomized controlled study demonstrated that a low-fat diet supplemented with fish oil decreased the number of MS relapses .
While the Swank diet may have some effectiveness, it is likely that the diet affects the course of disease through other means than lowered saturated fats.
Alternative/Adjunct Therapies for Multiple Sclerosis
There are several treatments that can mitigate and manage symptoms of MS. In this section, we review the literature involving natural options to manage MS.
1) Physiotherapy and Exercise
Physical therapy, or rehabilitation exercises, are helpful with reducing fatigue in patients who are not bed-bound .
A meta-analysis of many clinical studies demonstrated that exercise therapy is generally safe for MS with the exception of falls. The odds of relapse triggered by exercise is low . However, care should be taken to prevent exacerbation of symptoms from body heat generated by exercise.
2) Chiropractic Medicine for the Mitigation of Pain
Pain medication carries the risk of addiction. Chiropractic medicine serves as a viable alternative to the mitigation of chronic pain caused by MS . However, the lack of knowledge and moderate uptake of chiropractic medicine has been the limiting factor for widespread use .
Spinal manipulation in chiropractic medicine has been shown to mitigate acute and chronic lower back pain. This technique alleviates pressure and stiffness caused by other tissues in previous injuries or degenerative conditions .
Although chiropractic medicine shows strong potential to be a physical treatment for MS, more studies are needed to validate the efficacy of these treatments .
3) Massage Therapy
Massage therapy helps with MS, with benefits including :
- Pain reduction
- Reduced spasms
- Improved circulation
- Increased joint and limb mobility
- Decreased fatigue
The conditions that cause fatigue in MS are not well defined. Damages to the (central) nervous system such as MS lesions and inflammation can contribute to fatigue. Massage therapy has been shown to diminish fatigue and pain in MS patients .
Tight muscle tension can cause direct pain in the muscles by activating the pain receptors and restricting blood flow to that area (ischemia) .
Massage helps reduce the tension in the muscles leading to pain and spasm reduction. Massage also increases blood flow to affected areas. Other benefits of massage include relaxation and sleep improvement .
Relaxation caused by massage therapy also reduces anxiety and stress levels by increasing parasympathetic nervous system activity and decreasing cortisol .
Stress reduction not only increases the quality of life in MS patients but also helps manage physical symptoms .
Massage is a safe, non-invasive supplementary treatment option that helps manage stress and the physical symptoms of MS .
Reflexology is one of the most common and low-cost treatments in complementary medicine .
Reflexology is the study of how one part of the body is related to another. Application of the appropriate pressure and massage will stimulate other parts of the body, exerting its therapeutic effects .
Reflexology applies pressure with the thumb and fingers to specific points of the feet that are related to internal organs or glands .
Foot reflexology therapy effectively increases blood and lymph circulation, which helps stabilize the movement of muscles, joints, and tendons. This improvement in mobility also reinforces muscle strength and promotes relaxation .
- Reducing pain
- Stopping muscle spasms
- Reducing bladder and bowel problems
- Improving mobility
- Decreasing fatigue
In a randomized, sham-controlled clinical trial (53 participants) on reflexology, specific reflexology treatment has demonstrated alleviation in mobility, sensation, and urinary symptoms in MS patients .
Supplements for MS
Omega-3 Fatty Acids (FAs)
High intake of saturated fatty acids increases the risk of MS. Omega-3 fatty acids are a great alternative to reduce the risk of MS .
Omega-3 FAs are “essential fatty acids” that cannot be produced by the human body. As a result, this nutrient must come from the diet. Omega-3 FAs can be found in fish, fish oil, flaxseeds, flaxseed oil, soy products, soybean oil, and canola oil .
Administration of Omega-3 FAs reduces inflammation (inflammatory cytokines), which contributes to MS lesions .
Some of these fatty acids, such as DHA, can cross the blood-brain barrier and act as a major component of neuronal cell membranes. These compounds can not only act as an anti-inflammatory agent but also an inhibitor to T cell transportation to the brain (inhibiting MMP-9) .
However, the mechanism of this process is unknown .
In a study (DB-PCT), participants taking omega-3 FAs showed no significant difference compared to the controls. However, the results displayed a trend to improvement in the omega-3 treated subjects. The diet of the participants was a confounding effect in the study .
However, clinical trials have shown that vitamin D supplementation may be beneficial for MS .
Since vitamin D supplementation is generally safe, it is generally recommended as part of the treatment plan for MS.
Fullerene or C60 derivatives, when combined with drugs that block NMDA receptors, can help with MS. It reduces axonal degeneration, disease progression, monocyte attraction, and penetration of inflammatory cells in mouse models of MS .
Conventional Treatments for MS
Although there is no universal cure for MS, several therapies have proven effective in preventing the progression and relapses of the disease. There are no known therapies that promote the regeneration of these deficits because MS damages neurons in the brain .
Spontaneous recovery is rare if the damage to the neurons has progressed longer than 6 months .
MS long-term disability progresses slowly over many years. As a result, many treatments mitigate the short-term symptoms of the disease .
A patient with MS (relapsing-remitting MS or primary progressive MS) will commonly face relapses or attacks, which are flare-ups of new or recurring symptoms. Administration of high doses of glucocorticoids (methylprednisolone) or corticosteroids is the current routine therapy for acute relapses [49, 48].
The advantages of using glucocorticoids include rapid functional recovery in patients with acute attacks .
Limitations of Glucocorticoids
Administration of intravenous glucocorticoid can lead to potential side effects such as reddening of the face, ankle swelling, and a metallic taste in the mouth. Oral administration of glucocorticoids has more side effects including disturbed sleep, mood changes, and stomach problems .
High doses of glucocorticoids will not affect long-term disease improvement because of the treatment’s limited effects on MS lesions in the brain. The irreversible damages are not being regenerated .
Glucocorticoids may also have detrimental effects on bone density, increasing the risk of bone fracture .
2.) Disease-Modifying Therapies
Disease-modifying therapies (DMTs) were created and approved to manage the long-term effects of MS by slowing the natural course of the disease. Clinical studies have demonstrated that disease-modifying therapies (interferon beta, glatiramer acetate) have anti-inflammatory effects and slows the progression in relapsing-remitting multiple sclerosis (RRMS) patients .
Some disease-modifying therapies (IFNb-1a) promote nerve growth factors (NGF) to support the repair of neurological damages, leading to a decrease in lesion activities and disease relapse rates .
Disease-modifying treatments (IFNb, glatiramer acetate) also reduce the attack rates or relapses in relapsing-remitting multiple sclerosis patients and is effective at mitigating those attacks in the earlier stages .
Limitations of Disease-Modifying Therapies
Some common adverse side effects of disease-modifying therapies (IFNb, glatiramer acetate) include bruising, redness of the skin, pain, irritation, skin lesions, swelling, and sometimes cell death (necrosis) [55, 56].
Other rare potential side effects of disease-modifying therapies (IFNb) include immune system problems (psoriasis), insomnia, hearing loss, hair loss (alopecia), and in more severe and rare cases, liver damage [55, 57].
Primary progressive multiple sclerosis (PPMS) is characterized by the progressive worsening of neurologic functioning from the onset of the disease, usually targeting one part of the brain (usually the spinal cord). As the disease progresses, the symptoms increases. Progressive MS is a more advanced form of the disease and is more difficult not only to diagnose but also to treat .
Most of the disease-modifying therapy drugs (IFNb, glatiramer acetate) were approved and effective for relapsing-remitting MS. Most of these drugs are not effective against primary progressive MS [48, 53].
Primary progressive MS is problematic and tricky because patients do not respond to currently available treatments. About 10% of the patients have primary progressive MS, which accumulates neurological deterioration without relapses .
Ocrelizumab is a biologic immunosuppressive drug (anti-CD20 monoclonal antibody) that binds to immune cells (B cells) and prevents those cells from exerting harmful effects on the body .
During clinical trials, ocrelizumab has reduced relapse rates by 46%-47% and disability progression by 40%. Ocrelizumab also incredibly reduced inflammation and decreased the progression of lesions in the brain .
Limitations and Contraindications of Ocrelizumab
Ocrelizumab is contraindicated in patients with hepatitis B or allergic reactions to ocrelizumab. Ocrelizumab therapies can lead to increased risk for respiratory tract infections, viral infections of the brain (Progressive Multifocal Leukoencephalopathy), or breast cancer .
Ocrelizumab is a relatively new, approved drug and the FDA required Hoffmann-La Roche to continue post-marketing surveillance (phase IV trials) and report any risks, side effects, or adverse effects associated with the drug .
4.) Neuromuscular Electrical Stimulation
Neuromuscular electrical stimulation can be used to treat some of the physical symptoms of MS such as mobility problems, fatigue, and tremors.
Secondary progressive MS exhibits excessive oxidative stress and excitotoxicity. A case report of a 52-year-old female with secondary progressive MS have shown that dietary manipulation and neuromuscular electrical stimulations are synergistic in reducing oxidative stress and excitotoxicity .
Neuromuscular electrical stimulation has been effective in treating muscle spasms, muscle pain, and muscle degeneration (disuse atrophy) .
Neuromuscular electrical stimulation has also demonstrated efficacy in alleviating some of the symptoms of lower urinary tract complications in MS. In a study (DB-RCT), neuromuscular electrical stimulation significantly reduced incontinence .
Part 2 of a 3-Part Series
- Multiple Sclerosis Part 1: All About Multiple Sclerosis Part 1 – Causes, Symptoms, Diagnosis, and Risk Factors
- Multiple Sclerosis Part 2: Diets, Nutrition, and Alternative Treatments for Multiple Sclerosis
- Multiple Sclerosis Part 3: Epidemiology, Genetics, and Prevention