Case Report: EMS & Diet Interventions to improve MS

Two months following initiation of NMES, the patient reported that she had made multiple nutritional interventions to reduce oxidative stress and excito-toxicity (based upon her review of the medical literature). Her typical daily intake included 600 grams of cruciferous vegetables, 300 grams of brightly colored fruits or vegetables, and 60 to 100 grams of meat, poultry or fish, but no milk, eggs, or gluten-containing grains. The patient also began the following supplements: 2 g each of glutathione, N acetyl-cysteine, and taurine daily, and lithium orotate 300 mg twice daily.

Five months following initiation of NMES, to facilitate increasing both the number of minutes and muscle groups receiving NMES, the patient acquired an eight-channel electrotherapy unit, the TDR68® manufactured by Tone-Amatic. The NMES protocol then consisted of 20 to 40 min of NMES to the upper and lower abdominals, paraspinous, both gluteus, and left hamstrings, quadriceps, hip flexors, and tibia anterioralis muscle groups each morning, in addition to four or more 30-min sessions of NMES, using her portable device, while at work.

To assess interventions used and functional gains accrued by the patient, we used patient reports of function and average minutes per muscle group of electrotherapy, and PT clinical notes. Because the patient had participated in the North American Research Committee on Multiple Sclerosis (NARCOMS) [6] patient registry since 2005, we reviewed self-reported disability scales from her responses to the NARCOMS quality of life questions before and during the intervention.

Outcome

After 3 months of PT the patient’s back pain had diminished, but ambulation and sitting endurance were unchanged. She could do no more than 10 minutes of her HEP and still work due to fatigue limitations. However, after 2 weeks of NMES, the patient could complete 15 min of NMES-augmented HEP twice daily without difficulty. In addition the patient routinely completed another 60 to 90 min of NMES (while at work) of the abdominal, gluteus, and left anterior tibialis muscle groups. At 6 weeks the patient reported improved endurance for sitting and ambulation, although a cane was still required. The therapist observed gains in endurance and strength.

Within 2 weeks of initiating dietary interventions, the patient reported singing for the first time in 6 months. The therapist noted an increased rate of improvements in her strength and endurance, including muscles groups not receiving electrotherapy. The number of minutes and number of muscle groups were increased gradually. Four months following initiation of NMES the patient routinely did 30 minutes of NMES while completing her home exercise program each day and another 4 to 5 hours of NMES at much lower intensity through out the day while working or at home. Five months following initiation of NMES the patient stopped using her scooter, and 9 months after initiation of NMES the patient was able to bicycle 8 miles, including hills. One year following initiation of NMES and nutritional interventions the patient routinely rode her bicycle five miles to work.

The NARCOMS quality of life responses indicated gradual worsening of MS-related symptoms and disability scale prior to the intervention. Six weeks following initiation of NMES, improvement in overall symptoms and decreased fatigue were reported. Six months after initiation of NMES improvements were noted in overall MS symptoms, gait disability, and fatigue disability (Table 2).

Discussion

A 52-year-old white female with SPMS with 2 years of well-documented, gradual worsening of MS-related symptoms underwent NMES and dietary interventions to reduce oxidative stress and excito-toxicity. The patient experienced improved strength and endurance in response to the NMES. Following the dietary changes, the rate of improvements in function were more accelerated. To our knowledge this is the first published case report of the use of a NMES-augmented HEP and intensive nutritional support in a patient with progressive multiple sclerosis that resulted in significant reversal of disability.

The mechanisms by which NMES results in functional gains were likely due to changes both within the central nervous system (CNS) and the muscle. Physical activity has been associated with increases in nerve growth factor, brain-derived neurotrophic growth factor (BDNF), insulin-like growth factor, and glial growth factor [7,8].

Increased consumption of micronutrients appeared to have been synergistic with NMES. CNS response to circulating neurotrophins is dependent on the availability of intracellular adenosine triphosphate (ATP). Facilitating more effective mitochondrial bio-energetics with riboflavin, niacinamide, ubiquinone, and more antioxidants, could have facilitated enhanced responsiveness to neurotrophins, perhaps increasing dendritic sprouting and myelin generation.

Excessive neuronal excitation is present in experimental autoimmune encephalitis and patients with an acute MS relapse, primary progressive MS, and SPMS [9,10]. Blocking glutamate synthesis with taurine, glutathione, and N acetyl cysteine lowers excito-toxicity and has reversed axonal loss and disability in mice [11]. Antioxidants from food and nutritional supplements have been shown to inhibit T cell migration [12], block excito-toxicity [13], decrease oxidative stress [14] in both experimental autoimmune encephalitis and in multiple sclerosis patients.

Conclusion

NMES and dietary manipulation aimed at reduction of oxidative stress and excito-toxicity in a patient with a 4-year history of SPMS was associated with large gains in patient function. This case suggests that the nutritional intervention and NMES were synergistic. Whether either NMES alone or nutrition alone would have yielded as many functional gains is unknown. Additional pilot studies are warranted to determine if these effects can be replicated. Careful patient selection criteria will be required to identify individuals capable of complying with these interventions because of the substantial time commitment to complete the NMES sessions, tolerance for discomfort without immediate benefit, and commitment to what may be substantial changes in dietary habits.

Patient perspective

I had experienced gradual worsening of MS related symptoms since the diagnosis in 2000. It had been my expectation that continued worsening of my disability was inevitable. Following 18 months of neuromuscular electrical stimulation and intensive nutrition I can now bicycle 5 miles to work each day. I have noted when I am unable to eat 600 grams of cruciferous vegetables as when traveling, within 48 hours I experience subjective decline in energy and mental focus. When my electrical therapy device has had to be repaired and I have been without electrical stimulation for 48 hours I also experienced subjective decline in energy. It is my perception that two modalities (electrical therapy and antioxidant rich food and supplements) have additive, if not synergistic benefit to my recovery.

Acknowledgments