CAM Interventions for Multiple Sclerosis
Part 2—Integrative Nondietary Approaches
Sala Horowitz, PhD
Multiple sclerosis (MS) is an autoimmune disease of the
central nervous system that affects an estimated 400,000 peo-
ple in the United States and 2 million worldwide. Part 1 of this
2-part article reviewed the epidemiology and pathogenesis of
MS, usage of complementary and alternative medicine (CAM)
by patients, and evidence-based dietary interventions.1 This
article reviews other CAM modalities for treating MS.
Naturopathic Medicine
Naturopathic medicine, which encompasses a broad range of
CAM modalities, is used by many patients with MS. A study
assessed quality of life (QoL) in 45 patients who were random-
ly assigned to receive usual care, naturopathic medicine plus
usual care, or usual care plus MS education. Results favored the
naturopathic-treated group with respect to measures of general
health, neurologic impairment, and a timed walk.2
Exercise and Physical Therapy
Aerobic Exercise
In the past, there were concerns that patients might not be
able to tolerate therapeutic exercise because of fatigue and
heat-related exacerbation of symptoms.3 In 1996, a land-
mark study in which 54 patients with mild-to-moderate MS
were randomly assigned to either aerobic exercise or nonex-
ercise groups, provided the first scientific evidence that reg-
ular exercise could improve patients’ fitness and QoL. The
study looked at the effects of exercise training, consisting of
15 weeks of 40-minute sessions per week of combined arm
and leg ergometry. The training produced significant im-
provements in measures of fitness (including maximal aero-
bic capacity, upper- and lower-body muscle strength, body
composition, and serum lipid profile) and factors related
to QoL (mood, social interaction, recreation, and home
management ability).4
Physical activity and exercise training programs have been
associated with improved walking function, which is often
214 DOI: 10.1089/act.2011.17404 • MARY ANN LIEBERT, INC. • VOL. 17 NO. 4
AUGUST 2011
impaired in MS.5 Twelve weeks of body-weight supported
treadmill training at an exercise rehabilitation research center
significantly improved QoL and somewhat reduced fatigue in
6 patients with progressive MS.6
A single-blinded, randomized clinical trial compared three
bicycling exercise intensities engaged in by three groups of
patients for 20 minutes twice per week for 12 weeks as fol-
lows: continuous (n = 20); intermittent (n = 21); and combined
(n = 20). At 6 weeks, all participants improved in mobility as
assessed by 2-minute walk distance, compared with baseline.
Between 6 and 12 weeks, the highest number of adverse ef-
fects (primarily leg pain during cycling) and dropout rate were
for the higher exercise intensity groups. The researchers con-
cluded that, while the greatest benefit may be associated with
higher-intensity exercise, this level may be less well-tolerated.7
Evidence supports recommendations for participation in resis-
tance, endurance, and combined exercise of low-to-moderate
intensity for moderately impaired patients.8
The National Multiple Sclerosis Society (see Resources)
advises patients to consult with their physicians before ini-
tiating a new exercise program, and advises working with a
physical therapist experienced with MS and timing exercise
to prevent excessive fatigue and overheating. The organization
recommends yoga, adaptive t’ai chi chuan, and aquatics among
exercises suitable for patients with MS.9 These three forms of
exercise are discussed in the next sections.
Yoga
In a survey of 1980 people with MS, 30% responded that
they had participated in yoga classes. Of these patients, 57%
reported that they had found yoga to be “very beneficial.” In
addition to the demonstrated benefits of participation in any
physical activity, yoga may also be therapeutic by reducing
stress and improving cognitive ability by focused attention on
positioning and breathing techniques. Patients are advised to
opt for practices that incorporate props or supports rather than
ones that make difficult demands on physical strength, heat
tolerance, balance, and flexibility.10
A trial examined the effects of yoga and aerobic exercise on
cognitive function, fatigue, mood, and QoL. Sixty-nine pa-
ALTERNATIVE AND COMPLEMENTARY THERAPIES
 ALTERNATIVE AND COMPLEMENTARY THERAPIES • AUGUST 2011

tients were randomly assigned to one of 3 groups for 6 months Reflexology

(57 participants completed the intervention). The groups were: Researchers conducted a systematic review of 8 randomized
weekly Iyengar yoga (which emphasizes bodily alignment) plus clinical trials of varying methodological quality. The results
home practice; a weekly exercise class using a stationary bicycle of the review suggested that reflexology may be beneficial for
along with home practice; or wait-list control. At the end of 6 treating MS.19
months, significant improvement was shown on measures of
fatigue but not mood or cognitive improvement in both the
yoga and cycling class participants, compared with the wait- Resources
list group.11 Organizations
A 10-week randomized, prospective study of the effect of
Can Do Multiple Sclerosis
yoga compared with sports climbing showed that yoga in- 27 Main Street, Suite 303
creased selective attention by 17%. But neither form of exer- Edwards, CO 81632
cise produced reductions in spasticity, cognitive impairment, Tel: (970) 926-1990 or (800) 367-3101
Fax: (970) 926-1295
poor mood, or fatigue in 20 patients with relapsing–remitting E-mail: info@mscando.org
or progressive MS.12 Website: www.mscando.org
This national nonprofit organization takes a holistic view
T’ai Chi Chuan and Aquatic Exercise of optimizing the health and well-being of people with MS
through interdisciplinary program consultants, learning fo-
Although studies have confirmed that t’ai chi chuan pro- rums, peer-support programs, and research.
duces measurable improvements in balance, blood pressure, The Multiple Sclerosis International Federation (MSIF)
and cardiovascular health, no studies to date have involved Skyline House, 3rd Floor
200 Union Street
people with MS. However, a chapter of the National Mul- London, England SE1 0LX
tiple Sclerosis Society, that has been offering a t’ai chi chuan Phone: +44-(0)-20-7620-1911
class for several years, reports that adaptive t’ai chi chuan Fax: +44-(0)-20-7620-1922
E-mail: info@msif.org
is valuable for improving the proprioceptive sense (per- Website: www.msif.org
ception of movement and spatial orientation) of patients The MSIF links advocacy, research, and dissemination activi-
with MS.13 ties of national MS societies worldwide, and provides news,
Aquatic exercise, including ai chi (water-based t’ai chi ch- views, and an online newsletter.
uan), offered at some MS treatment centers,14 has been National Multiple Sclerosis Society
Website: www.nationalmssociety.org
shown to decrease fatigue and improve cardiovascular fitness National Offices:
in case reports.15 New York:
733 Third Avenue, 3rd floor
New York, NY 10017
Washington DC:
Other Mind–Body and Bodywork Practices 1100 New York Avenue, NW
Washington, DC 20005
Denver:
In addition to yoga, individuals with MS cited relaxation 900 South Broadway, Suite 200
and meditation, massage, and reflexology among the most Denver, CO 80209
Phone: (800) 344-4867
used CAM therapies in a U.K. survey.16
The Society helps people affected by MS to meet the chal-
lenges of living with the condition through the services and
Mindfulness Meditation programs of its 50-state network of chapters, support groups,
advocacy, funding of research, and facilitation of professional
In a study of 150 patients with relapsing–remitting or education. The Society’s website provides access to literature
secondary–progressive MS randomly assigned to an 8-week and videos on exercise and self-empowerment programs.
mindfulness training program or usual care, improvements in Books
QoL, and reductions of fatigue, depression, and anxiety were Complementary and Alternative Medicine
found postintervention and at 6-month follow-up in the train- and Multiple Sclerosis, 2nd ed.
ing program. Patient satisfaction and adherence to the pro- By Allen C. Bowling, MD, PhD
New York: Demos Medical Publishing, 2007
gram were also high.17
Managing Multiple Sclerosis Naturally:
A Self-Help Guide to Living with MS,
Massage Part Three—Physical and Complementary Therapies,
In a 4-week feasibility study, 30 patients with MS and rev. & updated ed.
By Judy Graham
chronic constipation were randomized to either receive ab- Rochester, VT: Healing Arts Press, 2010
dominal massage (self-administered or administered by a Website
health care provider) or a control group. Both groups re-
www.lowdosenaltrexone.org/
ceived bowel-management advice. While both groups ex-
perienced some alleviation of constipation, the massage This noncommercial website offers information updates on
low-dose naltrexone (LDN) and a discussion forum on LDN.
group had significant improvement at 4- and 8-weeks
follow-up.18

MARY ANN LIEBERT, INC. • VOL. 17 NO. 4

215
 ALTERNATIVE AND COMPLEMENTARY THERAPIES • AUGUST 2011
Neuromuscular Electrical Stimulation
Neuromuscular electrical stimulation is a physical therapy
modality approved by the U.S. Food and Drug Administra-
tion (FDA) for treating muscle spasm, pain, and disuse atro-
phy. Passive exercise machines provide nonaerobic exercise of
the arms and legs with minimal exertion. In a case series of
9 patients with primary– or secondary–progressive MS being
treated for gait disability, neuromuscular electrical stimula-
tion used in conjunction with a home-exercise program re-
sulted in measurable gains in ambulatory function.20
Functional electrical stimulation (FES) cycling is used to
facilitate neurologic recovery in patients with spinal-cord in-
juries. A pilot study with 5 patients with progressive MS gave
patients a FES cycle to use at home for 6 months. The exercise
was well-tolerated, and improvements were seen on measures
of walking and QoL.21
Anecdotal reports by patients suggest that whole-body vi-
bration therapy with a training machine may improve walking
ability, strength, flexibility, muscle tone, and balance.22 A ran-
domized, crossover pilot study randomly assigned 16 people
with MS to either a group who received 4 weeks of whole-
body vibration plus standard exercise 3 times per week, 2 weeks
of no intervention, and then 4 weeks of exercise alone 3 times
per week, or the treatment interventions in reverse order. Al-
though vibration therapy plus exercise reduced muscle spasms
and improved walking ability, the results did not reach statisti-
cal significance.23
Magnetic Stimulation
Magnetic Field Therapy
Magnetic field therapy has shown benefit in fatigue, a
symptom affecting ~ 75% of patients. In a randomized, dou-
ble-blinded, controlled pilot study, 37 patients with relapsing–
remitting MS with significant fatigue were assigned to an
intervention with either exposure to a Bio-Electro-Magnetic-
Energy-Regulation (BEMER) device (Innomed International
AG, Lichtenstein) for 8 minutes twice daily or an inactivated
device for 12 weeks. Patients used the mattress-like device—
which emits extremely weak, low-frequency pulsed electro-
magnetic fields—at home. After 12 weeks, there was a signifi-
cant difference on fatigue impact and severity scales in favor of
the treatment group.24
Transcranial Magnetic Stimulation
In a randomized, double-blinded, placebo-controlled
study, intermittent Transcranial magnetic theta-Burst
Stimulation (iTBS) was found to prime the effects of ex-
ercise therapy in the motor rehabilitation of patients with
MS. Thirty patients were randomized to three interven-
tions: iTBS plus exercise; sham stimulation plus exercise;
and iTBS alone. iTBS alone reduced spasticity, apparently
by inducing long-term excitability changes in the cere-
bral cortex.25
216 MARY ANN LIEBERT, INC. • VOL. 17 NO. 4
Biofeedback
Bladder dysfunction affects an estimated 75% of patients
with MS. Adding electromyography biofeedback (which mon-
itors muscle tension) to neuromuscular electrical stimulation
and pelvic-floor training decreased the number of urinary in-
continence episodes in a study of 74 patients assigned to ei-
ther active or placebo neuromuscular electrical stimulation in
conjunction with the other modality.26 In a clinical study of 52
patients with anorectal dysfunction (e.g., constipation, incon-
tinence), biofeedback was considered to be potentially most
useful for patients of lower bowel functioning status.27
Acupuncture
Two thirds of patients surveyed reported using acupunc-
ture for treating MS. Among the symptoms reduced in the
few studies of acupuncture specific to MS were fatigue, pain,
depression, muscle stiffness, spasticity, numbness, insomnia,
walking difficulties, coordination problems, and bladder and
bowel dysfunction.28 Bladder dysfunction was reported to de-
crease, following both standard acupuncture29 and electroacu-
puncture.30
Chiropractic
In a U.K. survey of CAM use by patients with MS, chiro-
practic (42%) was the third most popular modality reported
after physiotherapy (52%) and massage (44%). The majority
of respondents indicated that they would recommend this mo-
dality to other people with MS. Of those who did not utilize
chiropractic, 78% cited lack of knowledge about this treatment
option as the main reason. The MS therapy centers these peo-
ple had contacted offered physiotherapy and massage but not
chiropractic.31
Most patients with MS have some type of chronic pain
syndrome. Chiropractic integrated into a university medical
school–run chronic care facility showed efficacy in the treat-
ment of chronic spinal pain.32
Head and neck trauma is thought to play a contributing role
in the onset of MS (as well as in other neurologic disorders in-
cluding Parkinson’s disease).33 Thus, the International Upper
Cervical Chiropractic Association in Raleigh, North Carolina,
developed a protocol to diagnose and treat trauma-induced
injury to the upper cervical spine with chiropractic to correct
vertebral subluxation (misalignment). In an uncontrolled, non-
randomized clinical study of 81 patients with MS (n = 44) or
Parkinson’s disease (n = 37) over a 5-year period, 78 recalled
that they had experienced at least one head or neck trauma
prior to the onset of the disease. All patients were diagnosed
with upper cervical subluxation; the tests used were imaging
and radiographic tests. Chiropractic treatment to correct this
problem resulted in symptomatic improvement in 91% of the
patients with MS.33

Cooling Therapy
Cooling therapy has been described as a form of CAM
unique to treating MS. Because heat may produce an exacer-
bation of symptoms thought to result from adverse effects on
neural transmission, treatments have long included exposure
to cool showers, fans, air-conditioning, and specialized cooling
garments.34 The use of cooling therapy is based on extensive
patient experience rather than clinical studies.
Patient Education/Support Programs
Take Control, a program of the National Multiple Sclero-
sis Society, teaches patients to manage the fatigue common
to MS through six 2-hour group sessions of viewing a patient
education digital video disc (DVD), discussion, homework,
and workbooks. In a clinical trial, 30 participants were ran-
domly assigned to a group who immediately participated in
the program or a wait-list group. The study demonstrated the
program’s significant impact in reducing fatigue and bolstering
self-efficacy at all assessment points.35
In an analysis of its patient wellness management program,
the Can Do Multiple Sclerosis organization (see Resources)
found increased perceived well-being and self-efficacy irre-
spective of disease severity in 119 patients.36
According to the Motivational Model of Pain Self-Manage-
ment, readiness to engage in pain self-management behaviors
is mediated by beliefs about the importance of the coping be-
havior and self-efficacy (ability to carry out the behavior). A
study of a sample of 114 patients with MS and chronic pain
provided support for the model.37
Low-Dose Naltrexone
Clinical use of low-dose naltrexone (LDN) for treating im-
mune-related diseases, including MS, is growing.38 Naltrexone
is an opiate antagonist, which, at a 50 mg dose, is approved
by the Food and Drug Administration to treat addiction to
opioid drugs and alcohol. Much lower doses apparently work
by stimulating endogenous endorphins that regulate the body’s
immune system. In experimental autoimmune encephalomy-
elitis, an animal model of MS, LDN inhibited the onset and
progression of the disease.39
Available from compounding pharmacies, LDN can reduce
pain, spasticity, fatigue, and other MS symptoms. Because of
unsubstantiated claims that LDN is incompatible with stan-
dard interferon immunosuppressant drug therapy,40 patients
should consult their physicians before starting LDN and dis-
continuing usual care.41
The recommended dose is 4.5 mg taken at bedtime, except
for patients with MS who have muscle spasms; these patients
are advised to start treatment with 3 mg daily. Patients with
sleep disturbance lasting longer than 2 weeks may decrease the
dose to 3 mg or 2 mg daily. LDN should not be taken with
ALTERNATIVE AND COMPLEMENTARY THERAPIES • AUGUST 2011
narcotic-containing drugs (as it will block their action) but is
considered safe in pregnancy.40
A double-masked, placebo-controlled, crossover study evalu-
ated the efficacy of 8 weeks of treatment with 4.5 mg of LDN
nightly on the self-reported QoL of 60 patients with MS. LDN
was well-tolerated and associated with some improvement on
several QoL measures.42 Another randomized study of 96 pa-
tients validated the safety of LDN but did not result in signifi-
cant differences in QoL.43
It has recently been hypothesized that LDN could enhance
the pain-relieving effect of acupuncture for chronic pain syn-
dromes. This idea is based on the fact that both modalities act
on the opioid and cannabinoid receptors.44
Bee Venom Therapy and Stinging Nettle
A systematic literature review found marginal support for
bee venom therapy for MS, noting that its use is not wide-
spread because of the risk of an anaphylactic reaction.45 Sting-
ing nettle (Urtica dioica) is considered a safer anti-inflamma-
tory alternative.46
Treating Chronic Cerebral Venous Insufficiency
Preliminary findings suggest that chronic cerebral venous
insufficiency (CCVI), anomalies in the extracranial blood ves-
sels that drain blood from the brain and spinal cord, are more
prevalent in patients with MS than controls, may contribute to
CNS damage, and correlate with disease severity. Correction
of this condition by blood-vessel dilatation via angioplasty and
stents could theoretically influence MS pathophysiology.47
Until further evidence for the benefits of treatment for
CCVI are evaluated, the Multiple Sclerosis International Fed-
eration (see Resources)48 and the United States Department
of Veterans Affairs’ Multiple Sclerosis Center of Excellence in
Portland, Oregon,49 do not recommend this treatment outside
of clinical trials.
Hyperbaric Oxygen Therapy
There are also debates over hyperbaric oxygen therapy
(HBOT; oxygen administered under pressure) for treating
MS. Based on extensive clinical experience, the late Rich-
ard A. Neubauer, MD, who was a consultant in hyperbaric
medicine in Florida, concluded that, while HBOT is not a
cure for MS and intermittent long-term follow-up treatment
was necessary, HBOT altered the course of the disease fa-
vorably.50 In the United Kingdom, centers offer HBOT for
MS.51 Based on a systematic review several years ago of nine
randomized controlled trials evaluating the efficacy and safe-
ty for HBOT, reviewers did not recommend routine use of
this therapy.52 More-recent studies on HBOT for MS were
not found.
MARY ANN LIEBERT, INC. • VOL. 17 NO. 4
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 ALTERNATIVE AND COMPLEMENTARY THERAPIES • AUGUST 2011
Cannabis-Based Medicine
Research has shown that cannabinoids may be clinically use-
ful for controlling neuroinflammation,53 spasticity,54 and blad-
der dysfunction in patients with MS.55 In Canada, Sativex®
(Bayer Inc., Toronto), a spray containing extracts of Cannabis
sativa L., was conditionally approved in 2005 as an adjunctive
medicine for the relief of neuropathic pain in adults with MS
on the basis of clinical evidence.56 In the United Kingdom, Sa-
tivex® (GW Pharmaceuticals, United Kingdom) was approved
in 2010 for the treatment of MS spasticity; approval is being
sought in other European countries. In parts of the United
States, where medicinal marijuana is legal, patients with MS
are among the users.57 Along with concerns about potential
serious side-effects with long-term use, the National Multiple
Sclerosis Society considers evidence to date as inconclusive for
recommending treatment with cannabis or its derivatives.58
Other CAM Therapies
Aromatherapy, homeopathy, and hypnosis are among other
potentially beneficial CAM therapies for patients with MS.
However, studies have not been conducted specifically with
this patient population.34
Conclusion
Research has confirmed that exercise improves the fitness
and QoL of patients with MS. Larger-scale clinical trials are
warranted to provide further evidence for other nondietary
CAM therapies for MS providing symptomatic relief, includ-
ing electrical stimulation, biofeedback, acupuncture, bodywork-
based therapies, chiropractic, low-dose naltrexone, HBOT, and
medical cannabis. n
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