Dietary and lifestyle factors in multiple sclerosis progression: results from a 5-year longitudinal MRI study

Lifestyle changes and patient-reported outcomes over five years in a sample of people with multiple sclerosis after a single multimodal intensive lifestyle education workshop

INTRODUCTION

Modifiable lifestyle risk factors for progression of multiple sclerosis (MS) have been increasingly studied. This study employed a single-group design involving a one-off intensive live-in educational workshop on lifestyle modification for people with MS. We aimed to examine changes in a range of clinical and lifestyle variables and quality of life, self-efficacy, physical impact of MS and disability from baseline to 3- and 5-years post-intervention.

METHODS

95 participants completed the baseline survey. Data included lifestyle risk factors of diet quality, meat and dairy consumption, omega 3 and vitamin D supplementation, physical activity, stress reducing activities, and smoking status, and use of disease-modifying therapies (DMTs). Patient-reported outcomes included health-related quality of life, self-efficacy, physical impact of MS and disability. Generalised estimating equation models were used to account for within-participant correlation over time.

RESULTS

Sixty participants (63.2%) provided data at 3- and 5-years. Significant improvements in diet quality, omega 3 supplementation, and non-smoking were seen at both timepoints. Use of DMTs and disability remained unchanged. Mental (8.8- and 6.9-point) and physical (10.5- and 7.3-point) quality of life, and self-efficacy (2.4- and 1.9-point) improved significantly at 3- and 5-years, respectively. Physical impact of MS reduced from baseline to 3-years (-3.7 points) with a trend towards reduction at 5-years (-2.9 points; p = 0.079).

CONCLUSIONS

Education on lifestyle modification can lead to lifestyle modification and short and long-term improvements in mental and physical wellbeing outcomes. Results suggest potential value in lifestyle modification as an adjunctive component to standard therapy for MS.

Comorbid onset of cardiovascular diagnosis and long-term confirmed disability progression in multiple sclerosis: A 15-year follow-up study

BACKGROUND

People with multiple sclerosis (pwMS) have greater prevalence of comorbid cardiovascular diseases (CVD) when compared to the general population despite similar frequency of CV risk factors.

OBJECTIVE

Determine the impact of comorbid-onset of CVD diagnosis on long-term confirmed disability progression (CDP).

METHODS

276 pwMS (29 clinically isolated syndrome, 130 relapsing-remitting and 117 progressive) were clinically followed an average of 14.9 years, with a mean of 14.4 clinical visits. Retrospective electronic medical records (EMR) review determined CVD diagnoses (hypertension, hyperlipidemia, diabetes, and heart disease) at baseline and over the follow-up. CDP was determined with ≥1.0 point Expanded Disability Status Scale (EDSS) increase from EDSS <5.5, or ≥ 0.5-point increase from ≥5.5, and was sustained on next clinical visit.

RESULTS

A significantly shorter time to overall CDP was detected in 213 pwMS who had an existing (28 pwMS) or developed new onset (185 pwMS) of CVD, compared to 63 CVD-healthy pwMS over the follow-up (13.4 vs 15.9 years, Mantel-Cox p < 0.001), independent of baseline age and EDSS score. The CVD diagnosis preceded the CDP in 103 pwMS (55.7%), occurred after CDP in 71 pwMS (38.4%) and was concurrent in 11 pwMS (5.9%). Using mixed-effect models adjusted for significant age (F = 56.5, p < 0.001) and time effects (F = 67.8, p < 0.001), the CVD-onset diagnosis was associated with greater accrual of disability, as measured by longitudinal increase in EDSS score (F = 4.207, p = 0.04). Sex was not significant predictor of future disability in our cohort.

CONCLUSION

PwMS with an existing or new onset of comorbid CVD diagnosis showed accelerated disability worsening over long-term. There was no temporal relationship between the onset of CVD and CDP within the group that had CVD-onset diagnosis.

Association of Clinical Relapses With Disease Outcomes in Multiple Sclerosis Patients Older Than 50 Years

BACKGROUND AND OBJECTIVES

Relapse and MRI activity usually decline with aging but are replaced by progression independent of relapse activity (PIRA) in patients with multiple sclerosis (PwMS). However, several older PwMS continue to experience clinical relapses, and the impact on their disease remains undetermined. We aimed to determine the impact of an index relapse on disease outcomes in patients older than 50 years and to identify risk factors of disadvantageous outcomes.

METHODS

We performed a secondary analysis from 3 prospective cohorts in Germany. We evaluated all PwMS 50 years and older with a relapse ≤60 days before a baseline visit and at least 18 months of follow-up compared with a control cohort of PwMS without a relapse. Patients were stratified according to age ("50-54" vs "55-59" vs "60+") or disease outcomes ("stable" vs "active" vs "progressive," according to the Lublin criteria). We analyzed relapses, MRI activity, relapse-associated worsening, and PIRA. Regression analysis was performed to evaluate the association of specific baseline risk factors and treatment regimen changes with disease outcomes at month 18.

RESULTS

A total of 681 patients were included in the "relapse cohort" (50+: 361; 55+: 220; 60+: 100). The "control cohort" comprised 232 patients (50+: 117; 55+: 71; 60+: 44). Baseline epidemiologic parameters were balanced among cohorts and subgroups. We observed increased abundance of inflammatory activity and relapse-independent disability progression in the "relapse" vs "control" cohort. In the "relapse" cohort, we identified 273 patients as "stable" (59.7%), 114 patients as "active" (24.9%), and 70 patients as "progressive" (15.3%) during follow-up. Cardiovascular risk factors (CVRFs) and older age at baseline were identified as risk factors of progressive, whereas disease-modifying treatment (DMT) administration at baseline favored stable disease. DMT during follow-up was associated with stable over active, but not over progressive disease.

DISCUSSION

A relapse-suggesting underlying active disease-in PwMS older than 50 years was associated with continued disease activity and increased risk of PIRA. Presence of CVRF and absence of DMT at baseline appeared as risk factors of disadvantageous disease courses. An escalation of DMT switch was associated with stable over active but not progressive disease.

Associations between diet and disease progression and symptomatology in multiple sclerosis: A systematic review of observational studies

BACKGROUND

Although many people with MS (pwMS) modify their diet after diagnosis, there is still no consensus on dietary recommendations for pwMS. A number of observational studies have explored associations of diet and MS progression, but no studies have systematically reviewed the evidence. This systematic review aimed to provide an objective synthesis of the evidence for associations between diet and MS progression, including symptoms and clinical outcomes from observational studies.

METHODS

We performed a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic database searches were performed for studies completed up to 26 July 2023 using PubMed (Medline), Web of Science, CINAHL, Embase (Ovid), and Scopus, followed by citation and reference list checking. We included studies using diet quality scores or dietary indices. Studies assessing individual foods, nutrients, or dietary supplements were excluded. We used the Newcastle-Ottawa Scale to assess the risk of bias of included studies.

RESULTS

Thirty-two studies met the inclusion criteria. Of these, 20 were cross-sectional and 12 prospective. The most frequent outcomes assessed were disability (n = 19), quality of life (n = 12), fatigue (n = 12), depression (n = 9), relapse (n = 8), anxiety (n = 3), and magnetic resonance imaging (MRI) outcomes (n = 4). Based on prospective studies, this review suggests that diet might be associated with quality of life and disability. There were also potential effects of higher diet quality scores on improved fatigue, disability, depression, anxiety, and MRI outcomes but more evidence is needed from prospective studies.

CONCLUSIONS

Observational studies show some evidence for an association between diet and MS symptoms, particularly quality of life and disability. However, the impact of diet on other MS outcomes remains inconclusive. Ultimately, our findings suggest more evidence is needed from prospective studies and well-designed tailored intervention studies to confirm associations.

Towards new perspectives: A scoping review and meta-synthesis to redefine brain health for multiple sclerosis

BACKGROUND AND PURPOSE

Research promoting the health of the brain has increased exponentially over the last decade. The importance of 'brain health' for multiple sclerosis (MS), as one example, is a high priority. However, as research into the concept increases, so does varied use of the term.

METHODS

A scoping review, guided by the methodological framework of the Joanna Briggs Institute, was conducted to collate the evidence relating to brain health for MS. A comprehensive literature search incorporated six search strategies to retrieve both scientific and grey literature sources. All evidence sources were qualitatively charted and synthesized (meta-synthesis) according to their definition of brain health used, outcome measures and brain-healthy lifestyle elements.

RESULTS

Seventy evidence sources (34 peer reviewed, 36 grey literature) were eligible for inclusion. Of these, just over half (n = 40, 57%) provided a definition of brain health. The most common definition alluded to the biomedical model of neurological reserve (n = 22, 55%), a self-remodelling theory described to retain optimal brain function. Twenty-nine outcome measures of brain health were identified, the most frequent being magnetic resonance imaging metrics (n = 25, 83%). Physical activity was the most prevalent brain-healthy lifestyle element (n = 44), followed by avoidance of smoking (n = 26) and diet (n = 24).

CONCLUSIONS

Brain health should be considered a primary target for optimal disease and lifestyle management across the MS disease course. A working definition reflecting a shift from a medical lens towards broader biopsychosocial contexts that may influence brain health for people living with MS is proposed.

Blood metabolomic and transcriptomic signatures stratify patient subgroups in multiple sclerosis according to disease severity

There are no blood-based biomarkers distinguishing patients with relapsing-remitting (RRMS) from secondary progressive multiple sclerosis (SPMS) although evidence supports metabolomic changes according to MS disease severity. Here machine learning analysis of serum metabolomic data stratified patients with RRMS from SPMS with high accuracy and a putative score was developed that stratified MS patient subsets. The top differentially expressed metabolites between SPMS versus patients with RRMS included lipids and fatty acids, metabolites enriched in pathways related to cellular respiration, notably, elevated lactate and glutamine (gluconeogenesis-related) and acetoacetate and bOHbutyrate (ketone bodies), and reduced alanine and pyruvate (glycolysis-related). Serum metabolomic changes were recapitulated in the whole blood transcriptome, whereby differentially expressed genes were also enriched in cellular respiration pathways in patients with SPMS. The final gene-metabolite interaction network demonstrated a potential metabolic shift from glycolysis toward increased gluconeogenesis and ketogenesis in SPMS, indicating metabolic stress which may trigger stress response pathways and subsequent neurodegeneration.

Association between dietary inflammatory index and risk of demyelinating autoimmune diseases

Background: Considering limited data on the association between dietary inflammatory index (DII) and demyelinating autoimmune diseases, here, we studied this issue in the early diagnosed patients [e.g., preceding Multiple Sclerosis (MS) diagnosing level (Clinically Isolated Syndrome (CIS), and Radiologically Isolated Syndrome (RIS), MS, and Neuromyelitis Optica Spectrum Disorder (NMOSD)] using a case-control study among the Iranian population. Methods: A total of 291 subjects were selected as the cases (Patients with demyelinating autoimmune diseases including CIS, RIS, MS, and NMOSD, who were diagnosed less than six months before recruitment) and 297 others as controls. A 117-item semi-quantitative food frequency questionnaire (FFQ) was obtained from all of the participants and DII was calculated. Results: After controlling for potential confounders, adherence to a pro-inflammatory diet was associated with a higher risk of demyelinating autoimmune diseases (OR=2.05, 95% CI: 0.51, 3.58), EDSS (OR=2.02, 95% CI: 0.51, 3.53), active plaque (OR=1.90, 95% CI: 0.08, 3.71), higher lesion load (OR=2.11, 95% CI: 0.58, 3.64), LETM (OR=2.19, 95% CI: 0.27, 4.11), higher number of plaques (OR=2.11, 95% CI: 0.58, 3.64), and brain atrophy (OR=2.12, 95% CI: 0.57, 3.67). Conclusion: Our study suggests a possible link between the inflammatory potential of the diet and demyelinating autoimmune disease; however, further prospective cohort studies are needed to draw a causal link on this issue.

Multi-modal neuroimaging signatures predict cognitive decline in multiple sclerosis: A 5-year longitudinal study

BACKGROUND

Cognitive impairment is a hallmark of multiple sclerosis (MS) but is usually an under-recorded symptom of disease progression. Identifying the predictive signatures of cognitive decline in people with MS (pwMS) over time is important to ensure effective preventative treatment strategies. Structural and functional brain characteristics as measured by various magnetic resonance (MR) methods have been correlated with variation in cognitive function in MS, but typically these studies are limited to a single MR modality and/or are cross-sectional designs. Here we assess the predictive value of multiple different MR modalities in relation to cognitive decline in pwMS over 5 years.

METHODS

A cohort of 43 pwMS was assessed at baseline and 5 years follow-up. Baseline (input) data consisted of 70 multi-modal MRI measures for different brain regions including magnetic resonance spectroscopy (MRS), diffusion tensor imaging (DTI) and standard volumetrics. Age, sex, disease duration and treatment were included as clinical inputs. Cognitive function was assessed using the Audio Recorded Cognitive Screen (ARCS) and the Symbol Digit Modalities Test (SDMT). Prediction modelling was performed using the machine learning package - GLMnet, where a penalised regression was applied to identify multi-modal signatures with the most predictive value (and the least error) for each outcome.

RESULTS

The multi-modal approach to neuroimaging was able to accurately predict cognitive decline in pwMS. The best performing model for change in total ARCS (tARCS) included 16 features from across the various MR modalities and explained 54 % of the variation in change over time (R2=0.54, 95 % CI=0.48-0.51). The features included nine MRS, four volumetric and two DTI parameters. The model also selected disease duration, but not treatment, as a predictive feature. By comparison, the best model for SDMT included several of the same above features and explained 39 % of the change over time (R2=0.39, 95 % CI=0.48-0.51). Conventional volumetric measures were about half as good at predicting change in tARCS score compared to the best multi-modal model (R2=0.26 95 % CI:0.22-0.29). The clinical interpretation of the best predictive model for change in tARCS showed that cognitive decline could be predicted with >90 % accuracy in this cohort (AUC=0.92, SE=0.86 - 0.94).

CONCLUSION

Multi-modal MRI signatures can predict cognitive decline in a cohort of pwMS over 5 years with high accuracy. Future studies will benefit from the inclusion of even more MR modalities e.g., functional MRI, quantitative susceptibility mapping, magnetisation transfer imaging, as well as other potential predictors e.g., genetic and environmental factors. With further validation, this signature could be used in future trials with high-risk patients to personalise the management of cognitive decline in pwMS, even in the absence of relapses.

Excess weight increases the risk of sarcopenia in patients with multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is an autoimmune neurodegenerative disease. Nutritional status influences the course of the disease, however, its relationship with sarcopenia needs further investigation. The aim of the study was to identify patients with sarcopenia and assess its association with nutritional status and the clinical course of the disease.

METHODS

The study assessed 110 patients submitted to evaluation of sociodemographic characteristics, level of physical activity, nutritional status, and presence of sarcopenia. The clinical course of the disease, age at onset, disease duration, disease-modifying therapy, and expanded scale of disability status (EDSS) were investigated.

RESULTS

Mean age was 37.17 (SD = 10.60) years, disease duration was 6.29 years (SD = 4.65), with a predominance of female gender (80.90 %), relapsing-remitting clinical form (RRMS) (89.10 %) and mild level of disability (EDSS median = 1.92). The group had excess weight (53.6 %) according to body mass index (BMI) and abdominal fat accumulation measured by waist circumference (WC) (53.6 %). High percentage of fat mass ( % FM) was observed in 54.5 % and 38.2 % of the patients according to bioimpedance (BIA) and ultrasound (US), respectively. It was observed that 15.5 % were at risk for sarcopenia, which was associated with excess weight, and high % FM (p<0.05).

CONCLUSION

These findings highlight the importance of including nutritional status indicators, and sarcopenia assessment in the care of patients with MS.

Higher dietary quality is prospectively associated with lower MRI FLAIR lesion volume, but not with hazard of relapse, change in disability or black hole volume in people with Multiple Sclerosis

BACKGROUND

The influence of diet quality on multiple sclerosis (MS) progression or inflammatory activity is not well understood.

METHODS

Study participants with MS from the AusLong cohort, were followed annually (10 years, n = 223 post-onset). At baseline, 5 and 10-year reviews, indices of dietary quality - the Australian Recommended Food Score (ARFS) and Diet Quality Tracker (DQT) - were calculated from self-reported dietary intake data of the preceding 12 months (Food Frequency Questionnaire, Dietary Questionnaire for Epidemiological Studies v2). Associations were examined between measures of dietary quality with measures of MS progression and inflammatory activity hazard of relapse, annualised disability progression (Expanded Disability Status Scale, EDSS) and Magnetic Resonance Imaging (MRI) outcomes. MRI outcomes included fluid-attenuated inversion recovery (FLAIR, T2 MRI) lesion volume and black hole volume (T1 MRI) in the juxtacortical, periventricular, and infratentorial regions of the brain, as well as total calculated from the sum of the three regions.

RESULTS

A higher diet quality (at least with the ARFS) was associated with lower FLAIR lesion volume in the periventricular region only (highest vs lowest quartile: β=-1.89,95%CI=-3.64, -0.13, p = 0.04, periventricular FLAIR region median (IQR) for 5-year review: 4.41 (6.06) and 10-year review: 4.68 (7.27)). Associations with black hole lesion volume, hazard of relapse, and annualised EDSS progression, lacked in significance and/or dose-dependency.

CONCLUSION

We found evidence that diet quality may have a role in modulating one aspect of MS inflammatory activity (periventricular MRI FLAIR lesion volume), but not other MRI and clinical outcome measures.

The role of diet in multiple sclerosis onset and course: results from a nationwide retrospective birth-year cohort

OBJECTIVE

To examine (1) the association between childhood diet and developing MS, age of onset and onset type and (2) the association between diet at age 50 and disability and MRI volumes in people with MS (PwMS).

METHODS

The study enrolled 361 PwMS born in 1966 and 125 age- and sex-matched healthy controls (HCs). Information on individual dietary components (fruit, vegetables, red meat, oily fish, whole-grain bread and candy, snacks and fast food) and MS risk factors at the age of 10 and 50 years were collected using questionnaires. Overall diet quality score was calculated for each participant. Multivariable regression analyses were used to evaluate the association between diet at childhood and developing MS, age of onset and onset type and to evaluate diet at age 50, disability and MRI outcomes.

RESULTS

Poorer overall diet quality and individual dietary components during childhood (less whole-grain bread, more candy, snacks and fast food and oily fish) were associated with developing MS and onset type (all p < 0.05), but not with the age of onset. Fruit consumption at age 50 was associated with lower disability (Q3 vs. Q1: -0.51; 95% CI: -0.89 to -0.13). Furthermore, several individual dietary components at age 50 were associated with MRI volumetric measures. Higher-diet quality at age 50 was only associated with lower lesion volumes in PwMS (Q2 vs. Q1: -0.3 mL; 95% CI: -0.5 to -0.02).

INTERPRETATION

We demonstrate significant associations between dietary factors in childhood and developing MS, age of onset and onset type and between dietary factors at age 50 and disability and MRI-derived volumes.

Dietary Patterns and Their Associations with Symptom Levels Among People with Multiple Sclerosis: A Real-World Digital Study

INTRODUCTION

The objective of the study was to investigate long-term food intake patterns and establish possible associations between the inferred dietary habits and levels of reported symptoms among people with multiple sclerosis (MS) in Denmark.

METHODS

The present study was designed as a prospective cohort study. Participants were invited to register daily food intake and MS symptoms and were observed during a period of 100 days. Dropout and inclusion probabilities were addressed using generalized linear models. Dietary clusters were identified among 163 participants using hierarchical clustering on principal component scores. Associations between the dietary clusters and the levels of self-assessed MS symptoms were estimated using inverse probability weighting. Furthermore, the effect of a person's position on the first and second principal dietary component axis on symptom burden was investigated.

RESULTS

Three dietary clusters were identified: a Western dietary cluster, a plant-rich dietary cluster and a varied dietary cluster. Analyses further indicated a vegetables-fish-fruit-whole grain axis and a red-meat-processed-meat axis. The plant-rich dietary cluster showed reduction in symptom burden in nine pre-defined MS symptoms compared to the Western dietary cluster (between 19 and 90% reduction). This reduction was significant for pain and bladder dysfunction as well as across all nine symptoms (pooled p value = 0.012). Related to the two dietary axes, high intake of vegetables resulted in 32-74% reduction in symptom burden compared to low levels of vegetable intake. Across symptoms, this was significant (pooled p value = 0.015), also regarding walking difficulty and fatigue.

CONCLUSIONS

Three dietary clusters were identified. Compared to levels of self-assessed MS-related symptoms, and adjusted for potential confounders, the results suggested less symptom burden with increased intake of vegetables. Although the research design limits the possibilities of establishing causal inference, the results indicate that general guidelines for healthy diet may be relevant as a tool in coping with MS symptoms.

Feeding the gut microbiome: impact on multiple sclerosis

Multiple sclerosis (MS) is a multifactorial neurological disease characterized by chronic inflammation and immune-driven demyelination of the central nervous system (CNS). The rising number of MS cases in the last decade could be partially attributed to environmental changes, among which the alteration of the gut microbiome driven by novel dietary habits is now of particular interest. The intent of this review is to describe how diet can impact the development and course of MS by feeding the gut microbiome. We discuss the role of nutrition and the gut microbiota in MS disease, describing preclinical studies on experimental autoimmune encephalomyelitis (EAE) and clinical studies on dietary interventions in MS, with particular attention to gut metabolites-immune system interactions. Possible tools that target the gut microbiome in MS, such as the use of probiotics, prebiotics and postbiotics, are analyzed as well. Finally, we discuss the open questions and the prospects of these microbiome-targeted therapies for people with MS and for future research.

Rehabilitation treatment of multiple sclerosis

Multiple sclerosis is a slowly progressive disease, immunosuppressants and other drugs can delay the progression and progression of the disease, but the most patients will be left with varying degrees of neurological deficit symptoms, such as muscle weakness, muscle spasm, ataxia, sensory impairment, dysphagia, cognitive dysfunction, psychological disorders, etc. From the early stage of the disease to the stage of disease progression, professional rehabilitation treatment can reduce the functional dysfunction of multiple sclerosis patients, improve neurological function, and reduce family and social burdens. With the development of various new rehabilitation technologies such as transcranial magnetic stimulation, virtual reality technology, robot-assisted gait, telerehabilitation and transcranial direct current stimulation, the advantages of rehabilitation therapy in multiple sclerosis treatment have been further established, and more treatment means have also been provided for patients.

Overview of diet and autoimmune demyelinating optic neuritis: a narrative review

This review summarizes the cellular and molecular underpinnings of autoimmune demyelinating optic neuritis (ADON), a common sequela of multiple sclerosis and other demyelinating diseases. We further present nutritional interventions tested for people with multiple sclerosis focusing on strategies that have shown efficacy or associations with disease course and clinical outcomes. We then close by discuss the potential dietary guidance for preventing and/or ameliorating ADON.

Efficacy of Diet on Fatigue and Quality of Life in Multiple Sclerosis: A Systematic Review and Network Meta-analysis of Randomized Trials

BACKGROUND AND OBJECTIVE

Emerging evidence suggests a role for diet in multiple sclerosis (MS) care; however, owing to methodological issues and heterogeneity of dietary interventions in preliminary trials, the current state of evidence does not support dietary recommendations for MS. The objective of this study was to assess the efficacy of different dietary approaches on MS-related fatigue and quality of life (QoL) through a systematic review of the literature and network meta-analysis (NMA).

METHODS

Electronic database searches were performed in May 2021. Inclusion criteria were (1) randomized trial with a dietary intervention, (2) adults with definitive MS based on McDonald criteria, (3) patient-reported outcomes for fatigue and/or QoL, and (4) minimum intervention period of 4 weeks. For each outcome, standardized mean differences (SMDs) were calculated and included in random effects NMA to determine the pooled effect of each dietary intervention relative to each of the other dietary interventions. The protocol was registered at PROSPERO (CRD42021262648).

RESULTS

Twelve trials comparing 8 dietary interventions (low-fat, Mediterranean, ketogenic, anti-inflammatory, Paleolithic, fasting, calorie restriction, and control [usual diet]), enrolling 608 participants, were included in the primary analysis. The Paleolithic (SMD -1.27; 95% CI -1.81 to -0.74), low-fat (SMD -0.90; 95% CI -1.39 to -0.42), and Mediterranean (SMD -0.89; 95% CI -1.15 to -0.64) diets showed greater reductions in fatigue compared with control. The Paleolithic (SMD 1.01; 95% CI 0.40-1.63) and Mediterranean (SMD 0.47; 95% CI 0.08-0.86) diets showed greater improvements in physical QoL compared with control. For improving mental QoL, the Paleolithic (SMD 0.81; 95% CI 0.26-1.37) and Mediterranean (SMD 0.36; 95% CI 0.06-0.65) diets were more effective compared with control. However, the NutriGRADE credibility of evidence for all direct comparisons is very low because of most of the included trials having high or moderate risk of bias, small sample sizes, and the limited number of studies included in this NMA.

DISCUSSION

Several dietary interventions may reduce MS-related fatigue and improve physical and mental QoL; however, because of the limitations of this NMA, which are driven by the low quality of the included trials, these findings must be confirmed in high-quality, randomized, controlled trials.

Multiple Sclerosis in Mongolia; the First Study Exploring Predictors of Disability and Depression in Mongolian MS Patients

Mongolia is located at 45° north latitude in the center of the Asian continent, and about 80% of the territory is at 1000 m above sea level. Epidemiologically, multiple sclerosis (MS) has not been investigated in Mongolia, although there have been a few MS case reports. We investigated the characteristics of MS in Mongolia for the first time, focusing on the association between MS-related parameters and depression levels. We initiated cross-sectional analyses, using data from 27 MS patients aged 20 to 60 years in Ulaanbaatar, Mongolia. The patients completed a questionnaire on their lifestyles and clinical information. We classified the MS patients on the basis of disability levels using the expanded disability status scale (EDSS) scores: 11.1% mild disability and 88.9% moderate to severe disability (median EDSS score, 5.5). We also classified the patients on the basis of depression levels using the 9-item patient health questionnaire (PHQ-9) scores: 44.4% mild depression, 40.7% moderate depression, and 14.8% severe depression (mean PHQ-9's score, 9.96 ± 5.05). We used multivariate logistical regression analyses to identify predictors of EDSS or PHQ-9 scores. Disability levels were associated with vision and balance problems. Depression levels were associated with corticosteroid treatment; no patients were treated with disease-modifying drugs (DMDs). The odds ratios for disease onset age and treatment duration were associated with EDSS scores. In conclusion, MS onset age and treatment duration were independent predicting factors influencing the level of disability. Appropriate DMD treatment would lower the disability and depression levels.

Profit versus Quality: The Enigma of Scientific Wellness

The “best of both worlds” is not often the case when it comes to implementing new health models, particularly in community settings. It is often a struggle between choosing or balancing between two components: depth of research or financial profit. This has become even more apparent with the recent shift to move away from a traditionally reactive model of medicine toward a predictive/preventative one. This has given rise to many new concepts and approaches with a variety of often overlapping aims. The purpose of this perspective is to highlight the pros and cons of the numerous ventures already implementing new concepts, to varying degrees, in community settings of quite differing scales—some successful and some falling short. Scientific wellness is a complex, multifaceted concept that requires integrated experimental/analytical designs that demand both high-quality research/healthcare and significant funding. We currently see the more likely long-term success of those ventures in which any profit is largely reinvested into research efforts and health/healthspan is the primary focus.

Apparent changes in the epidemiology and severity of multiple sclerosis

Multiple sclerosis (MS) is an immunological disease that causes acute inflammatory lesions and chronic inflammation in the CNS, leading to tissue damage and disability. As awareness of MS has increased and options for therapy have come into use, a large amount of epidemiological data have been collected, enabling studies of changes in incidence and disease course over time. Overall, these data seem to indicate that the incidence of MS has increased, but the course of the disease has become milder, particularly in the 25 years since the first disease-modifying therapies (DMTs) became available. A clear understanding of these trends and the reasons for them is important for understanding the factors that influence the development and progression of MS, and for clinical management with respect to prevention and treatment decisions. In this Review, we consider the evidence for changes in the epidemiology of MS, focusing on trends in the incidence of the disease over time and trends in the disease severity. In addition, we discuss the factors influencing these trends, including refinement of diagnostic criteria and improvements in health-care systems that have increased diagnosis in people with mild disease, and the introduction and improvement of DMT.

A Mediterranean-type diet improved systemic inflammation in multiple sclerosis patients, as compared to the traditional Iranian diet: A single-center randomized controlled trial

BACKGROUND: There is overwhelming scientific evidence that dietary modifications is beneficial in neurodegenerative diseases like Multiple Sclerosis (MS). OBJECTIVE: The goal of this study was to explore the effects of modified Mediterranean Diet (mMeD) on systemic inflammation, anthropometric indices, and relapse rate in MS patients. METHODS: This single-center, randomized controlled trial compared mMeD and traditional Iranian diet (as control) during six months in 180 Relapsing-Remitting MS (RRMS) patients. Serum high sensitivity C Reactive Protein (hs-CRP), body weight, Body Mass Index (BMI), percent body fat, and relapse rate were evaluated at baseline, and 3 and 6 months later. Multivariate analysis of covariance test (MANCOVA; conducted by SPSS 24) was adjusted for age, gender, family history, duration of MS and education level. RESULTS: Of 261 screened patients (July 2018-February 2019), 180 patients were eligible; 68/90 as mMeD and 79/90 as control group completed the study. Self-reported adherence was excellent (95%). The mean change on the relapse rate was –0.54±0.9 compared to –0.03±0.4 for control group (P = 0.004). In addition, hs-CRP levels decreased in the mMeD group (–2.9±3.3 mg/L; P < 0.001) and mean changes were significant between two groups (P < 0.001). Anthropometric indices were modified in mMeD group, whereas between-group comparisons were not statistically different. CONCLUSIONS: Overall, mMeD improved inflammatory status and relapse rate in RRMS patients. Future trials with larger scale and longer duration should be conducted to confirm the role of diet as a disease-modifier in MS.

Health Promotion and Wellness in Neurologic Physical Therapy: Strategies to Advance Practice

BACKGROUND AND PURPOSE

Neurologic physical therapy (PT) can assist people with neurologic conditions and injuries to optimize their health and well-being by addressing barriers at the individual, relationship, community, and societal levels. The purpose of this special interest article is to provide consensus-driven strategies to address barriers to implementing health promotion and wellness (HPW)-related neurologic PT practice.

SUMMARY OF KEY POINTS

Environmental scan, literature review, and expert input were used to determine barriers and develop strategies. Barriers include lack of time; low knowledge, self-efficacy, and awareness; client complexity; and lack of HPW resources; as well as concerns regarding payment and scope of practice. Four key strategies emerged: (1) develop and disseminate a consensus-based scope of practice for HPW in neurologic PT; (2) increase knowledge of resources related to HPW; (3) promote delivery models for HPW-related neurologic PT; and (4) encourage advocacy, community building and partnership along the continuum of care.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Clinicians should practice to their full scope of HPW-related PT practice. This includes optimizing movement, including physical activity and fitness, as well as reinforcing the importance of healthy sleep, nutrition, stress, and smoking cessation. These activities address primary, secondary, and tertiary prevention. Clinicians are encouraged to report their experiences with HPW-focused delivery models and outcomes. Additional research is needed to understand the full impact of HPW on PT practice (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A364).

Influence of a High-Impact Multidimensional Rehabilitation Program on the Gut Microbiota of Patients with Multiple Sclerosis

Multiple sclerosis (MS) is a neurodegenerative inflammatory condition mediated by autoreactive immune processes. Due to its potential to influence host immunity and gut-brain communication, the gut microbiota has been suggested to be involved in the onset and progression of MS. To date, there is no definitive cure for MS, and rehabilitation programs are of the utmost importance, especially in the later stages. However, only a few people generally participate due to poor support, knowledge, and motivation, and no information is available on gut microbiota changes. Herein we evaluated the potential of a brief high-impact multidimensional rehabilitation program (B-HIPE) in a leisure environment to affect the gut microbiota, mitigate MS symptoms and improve quality of life. B-HIPE resulted in modulation of the MS-typical dysbiosis, with reduced levels of pathobionts and the replenishment of beneficial short-chain fatty acid producers. This partial recovery of a eubiotic profile could help counteract the inflammatory tone typically observed in MS, as supported by reduced circulating lipopolysaccharide levels and decreased populations of pro-inflammatory lymphocytes. Improved physical performance and fatigue relief were also found. Our findings pave the way for integrating clinical practice with holistic approaches to mitigate MS symptoms and improve patients’ quality of life.

Lung cancer risk in patients with multiple sclerosis: a Mendelian randomization analysis

BACKGROUND

The relationship of multiple sclerosis (MS) with lung cancer is under debate. Conventional observational studies have reported conflicting findings, but such studies are susceptible to confounding and reverse causation. With a Mendelian Randomization approach, we were able to evaluate the causality between MS and lung cancer.

METHODS

According to published genome-wide association studies (GWASs), we obtained 35 MS-related single-nucleotide polymorphisms, which were used as instrumental variables in our study. Summary data of individual-level genetic information were obtained from the International Lung Cancer Consortium (ILCCO), with a total of 15,861 controls and 11,348 cases; the latter is composed of patients with lung adenocarcinoma and squamous cell lung cancer. The inverse variance-weighted method was applied to estimate the causation between MS and lung cancer. To further evaluate the pleiotropy, the MR-Egger and Weighted median methods were implemented.

RESULTS

The results of MR analysis suggested a causal effect of MS on lung cancer incidence, with evidence of an increased risk for overall lung cancer [odds ratio (OR): 1.0648; 95% confidence interval (CI): 1.0163-1.1156; p = 0.0082]. However, subgroup analyses showed no significant causal relationships between MS and lung adenocarcinoma (OR = 1.0716; 95% CI 0.9840-1.1671, p = 0.1119) and squamous cell lung cancer (OR = 1.0284; 95% CI 0.9575-1.1045, p = 0.4424). In addition, no pleiotropy was found in our study.

CONCLUSION

Our study indicated that MS is a causal risk factor in the development of lung cancer. Further work is needed to elucidate the potential mechanisms.

Telerehabilitation in response to constrained physical distance: an opportunity to rethink neurorehabilitative routines

Ensuring proper dosage of treatment and repetition over time is a major challenge in neurorehabilitation. However, a requirement of physical distancing to date compromises their achievement. While mostly associated to COVID-19, physical distancing is not only required in a pandemic scenario, but also advised for several clinical conditions (e.g. immunocompromised individuals) or forced for specific social contexts (e.g. people living in remote areas worldwide). All these contexts advocate for the implementation of alternative healthcare models. The objective of this perspective is to highlight the benefits of remote administration of rehabilitative treatment, namely telerehabilitation, in counteracting physical distancing barriers in neurorehabilitation. Sustaining boosters of treatment outcome, such as compliance, sustainability, as well as motivation, telerehabilitation may adapt to multiple neurological conditions, with the further advantage of a high potential for individualization to patient's or pathology's specificities. The effectiveness of telerehabilitation can be potentiated by several technologies available to date: virtual reality can recreate realistic environments in which patients may bodily operate, wearable sensors allow to quantitatively monitor the patient's performance, and signal processing may contribute to the prediction of long-term dynamics of patient recovery. Telerehabilitation might spark its advantages far beyond the mere limitation of physical distancing effects, mitigating criticalities of daily neurorehabilitative practice, and thus paving the way to the envision of mixed models of care, where hospital-based procedures are complementarily integrated with telerehabilitative ones.

High density lipoprotein cholesterol and apolipoprotein A-I are associated with greater cerebral perfusion in multiple sclerosis

BACKGROUND

The pathophysiological mechanisms underlying the associations of multiple sclerosis (MS) neurodegeneration serum cholesterol profiles is currently unknown.

OBJECTIVE

To determine associations between lipid profile measures and cerebral perfusion-based indices in MS patients.

METHODS

Seventy-seven MS patients underwent 3 T MRI. Cerebral blood volume (CBV), time-to-peak (TTP) and mean transit time (MTT) measures were computed from dynamic susceptibility contrast (DSC) perfusion-weighted imaging (PWI) for normal-appearing brain tissue (NABT), GM, cortex, deep gray matter (DGM) and thalamus. Total cholesterol, low and high-density lipoprotein cholesterol (LDL-C and HDL-C) and the apolipoproteins (Apo), ApoA-I, ApoA-II, ApoB, ApoC-II and ApoE levels were measured in plasma. Age and body mass index (BMI)-adjusted correlations were used to assess the associations between PWI and lipid profile measures.

RESULTS

Higher HDL-C levels were associated with shorter MTT, which are indicative of greater perfusion, in NABT (p = 0.012), NAWM (p = 0.021), GM (p = 0.009), cortex (p = 0.014), DGM p = 0.015; and thalamus p = 0.015). The HDL-C-associated apolipoproteins, ApoA-I and ApoA-II, were associated with shorter MTT of the same brain regions (all p < 0.028). HDL-C and ApoA-I levels were also associated with shorter TTP, indicative of faster cerebral blood delivery. ApoC-II was associated with lower nCBV of the GM and cortex (p = 0.035 and p = 0.014, respectively).

CONCLUSION

The HDL pathway is associated with better global brain perfusion and faster cerebral blood delivery as measured by shorter MTT and TTP, respectively. ApoC-II may be associated with lower cortical and DGM perfusion.

Safety and feasibility of various fasting-mimicking diets among people with multiple sclerosis

BACKGROUND

Fasting-mimicking diets have shown promise in experimental autoimmune encephalitis and are currently being investigated among people with multiple sclerosis (MS). Ensuring adherence to diet changes is critical to determining the efficacy of such interventions.

OBJECTIVE

Our primary aim was to evaluate the safety and feasibility of several fasting-mimicking diets and investigate whether various levels of clinical support improve diet adherence among people with MS. Secondarily, this study evaluated the impact of fasting-mimicking diets on weight and patient-reported outcomes (PROs).

METHODS

We conducted three pilot studies (two randomized controlled for 6 months; one randomized with transition to single arm) restricting either the amount or timing of calorie intake over 24 or 48 weeks. Interventions included calorie restriction (daily or intermittently) or time-restricted feeding. Adherence measures varied across studies but were collected at study visits along with weight and PRO data.

RESULTS

A total of 90 participants enrolled; 70 completed the studies, with no serious adverse events reported. Overall adherence to the calorie restriction diets was poor. When participants were tasked with maintaining a diet in a pragmatic setting, neither previously completed intense clinical support and education, nor weekly electronic communication throughout the diet period appeared to improve diet adherence. Participants who were able to adhere to a calorie restriction diet predictably lost weight. In contrast to calorie restriction, adherence to a time-restricted feeding (TRF) diet was relatively good. No statistically significant changes in PROs were observed in an intention-to-treat analysis.

CONCLUSION

The role diet may play in clinical outcomes in MS remains unknown, as class I evidence is lacking. Diet adherence remains a primary barrier to the feasible conduct of large, randomized controlled diet trials. Strict adherence to a TRF dietary change may be more feasible than calorie restriction and should be considered in future fasting-mimicking diet trials. ClinicalTrials.gov Registry:A Pilot Study of Intermittent Calorie Restriction in Multiple Sclerosis - NCT02647502. A Pragmatic Trial of Dietary Programs in People with Multiple Sclerosis (MS) - NCT02846558.

Tonsillectomy in multiple sclerosis patients: Retrospective, case-controlled, exploratory study

BACKGROUND

Previous studies have shown an effect of tonsillectomy and greater risk for future autoimmune diseases. Currently there are only few outdated analyses of tonsillectomy and multiple sclerosis (MS) risk.

OBJECTIVE

To investigate the prevalence of tonsillectomy in MS patients and healthy controls (HCs).

METHODS

A total of 1000 subjects (779 MS patients and 221 HCs) completed a structured study questionnaire regarding MS diagnosis, age of onset, history of tonsillectomy, and age of tonsillectomy. In a subgroup of patients with available electronic medical records, Expanded Disability Status Scale (EDSS) scores at the time of recruitment and 5-years later were collected. Statistical analyses were performed with χ² test, odds ratio (OR), Student's t-test, Mann-Whitney U test, and ordinal regression..

RESULTS

The MS population had a greater percentage of patients with history of tonsillectomy when compared to HCs [39.5% vs. 31.7%, OR 1.411 (CI 1.027-1.938), p = 0.034], driven by participants aged 50 or older [45.7% vs. 36.1%, OR 1.495 (CI 1.037-2.155) p = 0.031]. There was no difference of the age at tonsillectomy (median 8.0 vs. 6.5 years old, p = 0.26). However, the RRMS patients had their tonsillectomy procedure performed significantly later when compared to HCs (median 6.5 vs. 9.0 years old, p = 0.049). In an analysis of RRMS patients with available longitudinal data (n = 459), patients with a history of tonsillectomy were significantly older and had a longer disease duration (p < 0.001 and p = 0.025). After adjusting for the demographic differences, no history of tonsillectomy remained significant predictor of lower EDSS score categories both at the first (estimate = -0.467, Wald = 6.68, 95% CI -0.82 to -0.11, p = 0.01) and second timepoint (estimate = -0.376, Wald = 4.4, 95% CI -0.73 to -0.02 p = 0.037).

CONCLUSION

When compared to HCs, a greater percentage of MS patients underwent tonsillectomy. The role of tonsils, its relationship with early infection rates and/or antibiotic use in MS should be further investigated.

Gut-brain communication in demyelinating disorders

Multiple Sclerosis (MS) is an autoimmune demyelinating disorder resulting from the interplay of genetic predisposition and environmental variables, including gut microbiota, diet and life style factors. Here, we first discuss the evidence supporting the effect of early life events, diet and body mass index on the composition of the microbiota, and then review studies on gut dysbiosis conducted in MS patients and in animal models. We address the effect of disease, immunomodulatory therapies, diet and probiotics on enrichment or depletion of gut microbial species. Finally, we discuss the ability of gut bacteria to produce toxins and metabolites which serve as signals for the cross-talk between the gut and the brain.

Longitudinal analysis of cerebral aqueduct flow measures: multiple sclerosis flow changes driven by brain atrophy

Background

Several small cross-sectional studies have investigated cerebrospinal fluid (CSF) flow dynamics in multiple sclerosis (MS) patients and have reported mixed results. Currently, there are no longitudinal studies that investigate CSF dynamics in MS patients.

Objective

To determine longitudinal changes in CSF dynamics measured at the level of aqueduct of Sylvius (AoS) in MS patients and matched healthy controls (HCs).

Materials and methods

Forty (40) MS patients and 20 HCs underwent 3T MRI cine phase contrast imaging with velocity-encoded pulse-gated sequence at baseline and 5-year follow-up. For atrophy determination, MS patients underwent additional high-resolution 3D T1-weighted imaging. Measures of AoS cross-sectional area (CSA), average systolic and diastolic velocity peaks, maximal systolic and diastolic velocity peaks and average CSF flow rates were determined. Brain atrophy and ventricular CSF (vCSF) expansion rates were determined. Cross-sectional and longitudinal changes were derived by analysis of covariance (ANCOVA) and paired repeated tests. Confirmatory general linear models were also performed. False discovery rate (FDR)-corrected p-values lower than 0.05 were considered significant.

Results

The MS population demonstrated significant increase in maximal diastolic peak (from 7.23 to 7.86 cm/s, non-adjusted p = 0.037), diastolic peak flow rate (7.76 ml/min to 9.33 ml/min, non-adjusted p = 0.023) and AoS CSA (from 3.12 to 3.69 mm², adjusted p = 0.001). The only differentiator between MS patients and HCs was the greater AoS CSA (3.58 mm² vs. 2.57 mm², age- and sex-adjusted ANCOVA, p = 0.045). The AoS CSA change was associated with vCSF expansion rate (age- and sex-adjusted Spearman’s correlation r = 0.496, p = 0.019) and not with baseline nor change in maximal velocity. The expansion rate of the vCSF space explained an additional 23.8% of variance in change of AoS CSA variance when compared to age and sex alone (R² = 0.273, t = 2.557, standardized β = 0.51, and p = 0.019).

Conclusion

MS patients present with significant longitudinal AoS enlargement, potentially due to regional atrophy changes and ex-vacuo expansion of the aqueduct.

Does a modifiable risk factor score predict disability worsening in people with multiple sclerosis?

Background

Risk factors for chronic disease include smoking, hazardous alcohol consumption, physical inactivity, unhealthy body mass index and poor diet (SNAP factors). In multiple sclerosis (MS) SNAP factors are associated with health outcomes such as disability in cross-sectional studies, but longitudinal data are lacking.

Objective

The objective of this study was to assess whether a combined SNAP risk score predicts disability worsening.

Methods

Longitudinal self-reported data from two time-points 2.5 years apart from an international survey of 1225 people with MS were used in linear regression models adjusted for potential confounding. Disability worsening was measured using the patient-derived Multiple Sclerosis Severity Score.

Results

The majority (62%) had two or more risk factors, with insufficient fruit and vegetable intake (83%), unhealthy body mass index (42%) and physical inactivity (33%) most common. Some SNAP factors at follow-up were associated with disability at follow-up (cross-sectionally), and in addition there was some evidence that increasing risk factors was associated with disability worsening over the 2.5 year study period. Baseline SNAP score was not predictive of disability worsening at follow-up, however.

Conclusion

Known risk factors for morbidity and mortality were common and associated with disability cross-sectionally, but not prospectively. Further studies using longer time frames, objective measures and interventions may elucidate potential benefits from changes in risk factors on MS outcomes.

Vascular aspects of multiple sclerosis: emphasis on perfusion and cardiovascular comorbidities

INTRODUCTION

Multiple sclerosis (MS) is a chronic inflammatory, demyelinating, and neurodegenerative disease of the central nervous system. Over the last two decades, more favorable MS long-term outcomes have contributed toward increase in prevalence of the aged MS population. Emergence of age-associated pathology, such as cardiovascular diseases, may interact with the MS pathophysiology and further contribute to disease progression. Areas covered: This review summarizes the cardiovascular involvement in MS pathology, its disease activity, and progression. The cardiovascular health, the presence of various cardiovascular diseases, and their effect on MS cognitive performance are further explored. In similar fashion, the emerging evidence of a higher incidence of extracranial arterial pathology and its association with brain MS pathology are discussed. Finally, the authors outline the methodologies behind specific perfusion magnetic resonance imaging (MRI) and ultrasound Doppler techniques, which allow measurement of disease-specific and age-specific vascular changes in the aging population and MS patients. Expert opinion: Cardiovascular pathology significantly contributes to worse clinical and MRI-derived disease outcomes in MS. Global and regional cerebral hypoperfusion may be associated with poorer physical and cognitive performance. Prevention, improved detection, and treatment of the cardiovascular-based pathology may improve the overall long-term health of MS patients.