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Canadian Physical Activity Guidelines for Adults with MS Presented by Susan Ehler BScPT

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Canadian Physical

Activity Guidelines for

Adults with MS Presented by Susan Ehler BScPT

What are the guidelines Guidelines established for adults ages 18-64 with minimal

to moderate disability from RR or progressive forms of MS

Guidance for individuals with MS as well as health care

professionals working with them

What will the guidelines tell

me How a person with MS can add safe appropriate and

effective physical activity into their day

A reference for appropriate physical activity levels

Minimum freq intensity duration and type of physical

activity needed for improved fitness for adults with MS

How will the guidelines help

Following the Guidelines can improve fitness related to

aerobic endurance and muscle strength

Fitness is especially important for people with MS as rates

of inactivity and deconditioning are high

May reduce fatigue improve mobility and enhance quality

of life

What if I canrsquot meet the

Guidelines For those currently inactive activities performed at a

lower level can still result in benefits

Gradual increase toward recommended Guidelines

Are there any risks No scientific evidence that following these Guidelines will

result in relapse of MS symptoms or worsen fatigue or

health related quality of life

Potential benefits exceed potential risks associated with

physical activity

Who created the Guidelines International standard for health guideline development

Researchers reviewed all literature

Consensus panel met to review research

Consensus panel developed Guidelines based on

research

Guidelines circulated to experts for review and

feedback

Guidelines revised based on feedback

Who is releasing the

Guidelines Canadian Society of Exercise Physiology

MS Society of Canada

ParticipACTION

Canadian Institutes of Health Research

Getting started Setting goals

Studies show that people who set challenging but achievable goals are more likely to be active

Making an action plan

Include what where when how long and intensity level

How to set exercise goals 1) Establish what you can do now

2) Set a goal for this week

3) Set a goal for this month

4) Check in at the end of each week to see how you are

doing

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

What are the guidelines Guidelines established for adults ages 18-64 with minimal

to moderate disability from RR or progressive forms of MS

Guidance for individuals with MS as well as health care

professionals working with them

What will the guidelines tell

me How a person with MS can add safe appropriate and

effective physical activity into their day

A reference for appropriate physical activity levels

Minimum freq intensity duration and type of physical

activity needed for improved fitness for adults with MS

How will the guidelines help

Following the Guidelines can improve fitness related to

aerobic endurance and muscle strength

Fitness is especially important for people with MS as rates

of inactivity and deconditioning are high

May reduce fatigue improve mobility and enhance quality

of life

What if I canrsquot meet the

Guidelines For those currently inactive activities performed at a

lower level can still result in benefits

Gradual increase toward recommended Guidelines

Are there any risks No scientific evidence that following these Guidelines will

result in relapse of MS symptoms or worsen fatigue or

health related quality of life

Potential benefits exceed potential risks associated with

physical activity

Who created the Guidelines International standard for health guideline development

Researchers reviewed all literature

Consensus panel met to review research

Consensus panel developed Guidelines based on

research

Guidelines circulated to experts for review and

feedback

Guidelines revised based on feedback

Who is releasing the

Guidelines Canadian Society of Exercise Physiology

MS Society of Canada

ParticipACTION

Canadian Institutes of Health Research

Getting started Setting goals

Studies show that people who set challenging but achievable goals are more likely to be active

Making an action plan

Include what where when how long and intensity level

How to set exercise goals 1) Establish what you can do now

2) Set a goal for this week

3) Set a goal for this month

4) Check in at the end of each week to see how you are

doing

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

What will the guidelines tell

me How a person with MS can add safe appropriate and

effective physical activity into their day

A reference for appropriate physical activity levels

Minimum freq intensity duration and type of physical

activity needed for improved fitness for adults with MS

How will the guidelines help

Following the Guidelines can improve fitness related to

aerobic endurance and muscle strength

Fitness is especially important for people with MS as rates

of inactivity and deconditioning are high

May reduce fatigue improve mobility and enhance quality

of life

What if I canrsquot meet the

Guidelines For those currently inactive activities performed at a

lower level can still result in benefits

Gradual increase toward recommended Guidelines

Are there any risks No scientific evidence that following these Guidelines will

result in relapse of MS symptoms or worsen fatigue or

health related quality of life

Potential benefits exceed potential risks associated with

physical activity

Who created the Guidelines International standard for health guideline development

Researchers reviewed all literature

Consensus panel met to review research

Consensus panel developed Guidelines based on

research

Guidelines circulated to experts for review and

feedback

Guidelines revised based on feedback

Who is releasing the

Guidelines Canadian Society of Exercise Physiology

MS Society of Canada

ParticipACTION

Canadian Institutes of Health Research

Getting started Setting goals

Studies show that people who set challenging but achievable goals are more likely to be active

Making an action plan

Include what where when how long and intensity level

How to set exercise goals 1) Establish what you can do now

2) Set a goal for this week

3) Set a goal for this month

4) Check in at the end of each week to see how you are

doing

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

How will the guidelines help

Following the Guidelines can improve fitness related to

aerobic endurance and muscle strength

Fitness is especially important for people with MS as rates

of inactivity and deconditioning are high

May reduce fatigue improve mobility and enhance quality

of life

What if I canrsquot meet the

Guidelines For those currently inactive activities performed at a

lower level can still result in benefits

Gradual increase toward recommended Guidelines

Are there any risks No scientific evidence that following these Guidelines will

result in relapse of MS symptoms or worsen fatigue or

health related quality of life

Potential benefits exceed potential risks associated with

physical activity

Who created the Guidelines International standard for health guideline development

Researchers reviewed all literature

Consensus panel met to review research

Consensus panel developed Guidelines based on

research

Guidelines circulated to experts for review and

feedback

Guidelines revised based on feedback

Who is releasing the

Guidelines Canadian Society of Exercise Physiology

MS Society of Canada

ParticipACTION

Canadian Institutes of Health Research

Getting started Setting goals

Studies show that people who set challenging but achievable goals are more likely to be active

Making an action plan

Include what where when how long and intensity level

How to set exercise goals 1) Establish what you can do now

2) Set a goal for this week

3) Set a goal for this month

4) Check in at the end of each week to see how you are

doing

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

What if I canrsquot meet the

Guidelines For those currently inactive activities performed at a

lower level can still result in benefits

Gradual increase toward recommended Guidelines

Are there any risks No scientific evidence that following these Guidelines will

result in relapse of MS symptoms or worsen fatigue or

health related quality of life

Potential benefits exceed potential risks associated with

physical activity

Who created the Guidelines International standard for health guideline development

Researchers reviewed all literature

Consensus panel met to review research

Consensus panel developed Guidelines based on

research

Guidelines circulated to experts for review and

feedback

Guidelines revised based on feedback

Who is releasing the

Guidelines Canadian Society of Exercise Physiology

MS Society of Canada

ParticipACTION

Canadian Institutes of Health Research

Getting started Setting goals

Studies show that people who set challenging but achievable goals are more likely to be active

Making an action plan

Include what where when how long and intensity level

How to set exercise goals 1) Establish what you can do now

2) Set a goal for this week

3) Set a goal for this month

4) Check in at the end of each week to see how you are

doing

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Are there any risks No scientific evidence that following these Guidelines will

result in relapse of MS symptoms or worsen fatigue or

health related quality of life

Potential benefits exceed potential risks associated with

physical activity

Who created the Guidelines International standard for health guideline development

Researchers reviewed all literature

Consensus panel met to review research

Consensus panel developed Guidelines based on

research

Guidelines circulated to experts for review and

feedback

Guidelines revised based on feedback

Who is releasing the

Guidelines Canadian Society of Exercise Physiology

MS Society of Canada

ParticipACTION

Canadian Institutes of Health Research

Getting started Setting goals

Studies show that people who set challenging but achievable goals are more likely to be active

Making an action plan

Include what where when how long and intensity level

How to set exercise goals 1) Establish what you can do now

2) Set a goal for this week

3) Set a goal for this month

4) Check in at the end of each week to see how you are

doing

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Who created the Guidelines International standard for health guideline development

Researchers reviewed all literature

Consensus panel met to review research

Consensus panel developed Guidelines based on

research

Guidelines circulated to experts for review and

feedback

Guidelines revised based on feedback

Who is releasing the

Guidelines Canadian Society of Exercise Physiology

MS Society of Canada

ParticipACTION

Canadian Institutes of Health Research

Getting started Setting goals

Studies show that people who set challenging but achievable goals are more likely to be active

Making an action plan

Include what where when how long and intensity level

How to set exercise goals 1) Establish what you can do now

2) Set a goal for this week

3) Set a goal for this month

4) Check in at the end of each week to see how you are

doing

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Who is releasing the

Guidelines Canadian Society of Exercise Physiology

MS Society of Canada

ParticipACTION

Canadian Institutes of Health Research

Getting started Setting goals

Studies show that people who set challenging but achievable goals are more likely to be active

Making an action plan

Include what where when how long and intensity level

How to set exercise goals 1) Establish what you can do now

2) Set a goal for this week

3) Set a goal for this month

4) Check in at the end of each week to see how you are

doing

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Getting started Setting goals

Studies show that people who set challenging but achievable goals are more likely to be active

Making an action plan

Include what where when how long and intensity level

How to set exercise goals 1) Establish what you can do now

2) Set a goal for this week

3) Set a goal for this month

4) Check in at the end of each week to see how you are

doing

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

How to set exercise goals 1) Establish what you can do now

2) Set a goal for this week

3) Set a goal for this month

4) Check in at the end of each week to see how you are

doing

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Tips to achieve your goals Be flexible

Be steady

Share your goals

Be aware of your body

Celebrate your success

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Making an action plan What

Where

When

How long

Intensity level

Back up plan

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Itrsquos all about you Your ability

Do what you can towards meeting the guidelines

Your way

Pick moderate intensity activities that feel good and that

you enjoy

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

The Guidelines

30 mins aerobic activity 2 timesweek

Strength training exercises for major muscle groups 2

timesweek

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

How hard do I exercise Aerobic activities should be moderate in intensity ndash move

and talk

Strength ndash 2 sets of 10-15 reps for all major muscle

groups

Strength ndash challenging to

finish 2nd set

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

How much rest Aerobic and strength training can be done on the same

day

Avoid strength training the same muscle group 2 days in a

row

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Tips to avoid injury Progress at your own pace

Consult a health professional for activity suggestions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

How do I stay cool Air conditioned spaces on hot humid days

Drink lots of cool water

Use a spray bottle

Consider pool-based activities

Monitor how you are feeling Move to a cool spot and

rest

Cooling equipment such as a vest collar or cuffs

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Activity suggestions Aerobic

Walk or bike

Arm ergometer

Dance

Swim or aqua fitness

Team sports or active family gamesvideo games

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Activity suggestions Strength training

Lift weights ndash free weights or machines

Resistance bands

Body weight ex ndash push ups squats

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Other activities These exercises can help build flexibility balance and body awareness

Tai chi

Yoga

Pilates

These are great activities to do in addition to the activity guidelines

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Exercise and Multiple

Sclerosis

Dr Christine Short

Associate Professor

Dalhousie University Halifax

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Why Exercise

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Whatrsquos the evidence In 1996 the National MS society funded the first study

to look at the affects of exercise on MS Many have

followed

Improved fatigue

Improved walking speed

Improved strength

Improved quality of life

Improved function

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Barriers People with MS can have many barriers to exercising

Weakness

Fatigue

Heat sensitivity

Spasticity

Pain

Transportation

Financial

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Weakness Progressive resistance exercises are the most effective

way to increase muscle strength even in patients with

central nervous system dysfunction

Effective even in profoundly weak muscles in MS

Kraft 1996

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Weakness mimics Opposing spasticity

Progressive weakness with activity

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Weakness Treatment

Progressive resistive exercises (PREs)

Bracing (eg ankle dorsiflexor weakness)

Maximize spasticity management

Nerve stimulation

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Fatigue Most common self identified symptom in MS

77 of patients whit MS

Most Pronounced in the afternoon

Kraft 1986

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Fatigue management Rule out aggravating factors Depression Thyroid dysfunction

Medications Amantidine Modafanil pemoline

Non-pharmacological treatment Cooling Exercise Energy conservation techniques

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Heat sensitivity Exercise in a cool enviornment

Cooling garments

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Spasticity Common in MS

May go unrecognized

Spasticity is different to different people

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Impact of Spasticity

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Impact of Spastic Disorders on Quality of Life

I spasticity all bad

No

Maintains muscle bulk

Mechanical factor in improving venous flow

preventing venous stasis complications (phlebitis and

DVT)

Some individuals use their tone to perform certain

ADLs

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Spasticity treatment

Non-pharmachologic

Therapeutic Exercise

Modalities

Bracing

Positioning Splints

Serial Casting

Seating Systems

ADL and Mobility Equipment

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Non-pharmachologic Exercise

Rosche J Paulus C etal Spinal Cord 1997

Cycling in MS patients and lower extremity spasticity

pre and post EMG showed a definite reduction in motor

neuron excitability post cycling

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Non-pharmachologic

Stretching

Fundamental underpinning of all spasticity

management

Must be done frequently

Inverse relationship between length of muscle

tendonous unit and the stimulus to induce spasticity

Prevents contracture and skin comp

A stretch must be maintained to impact spasticity

Otis JC et Al J pediatr orthopedics 1985

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Non-pharmachologic Strengthening

spasticity inactivity weakness

Exercise must be judicious to avoid

excessive fatigue

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Non-pharmachologic Orthotics

wheelchairs

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Oral Medications

Baclofen

Tizanidine

Gabapentin

Benzodiazepines

Dantrolene

sodium

Clonidine

Cyproheptadine

Cannabinoids

4-aminopyridine

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Botulinum Toxin Produced by the bacterium Clostridium botulinum

Seven serotypes (A-G) only ldquoArdquo and ldquoBrdquo approved for clinical use

Trade names of BTX-A BOTOXreg (Allergan) Xeominreg (Merz) DYSPORTreg (Ipsen Ltd)

Conversion ratio 1 Unit BOTOX~3-5 Units Dysport

Trade name of BTX-B from Elan MyoblocTM in USA NeuroBlocreg in Europe

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Pre and Post BTXA

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Fampridine (4-Aminopyridine 4-AP)

Freely crosses BBB

Blocks fast-activating voltage-gated K+ channels

Prolongation of action potential

Increased safety factor for firing action potential

Possible enhancement of synaptic transmission

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Without

Fampridine

K+

K+

With Fampridine

Mechanism of Fampridine History of Fampridine-

SR

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

83

348

0

10

20

30

40

50

Placebo (N=72) Fampridine-SR 10mg bid (N=224)

Plt0001

MS-F203 Fampridine-SR Increases

Timed Walk Response

Protocol-Specified Primary Endpoint

Proportion

plusmn 95

Confidence

Limits

Placebo

(N=72)

Fampridine-SR 10 mg

(N=224)

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

MS-F204 Confirms Fampridine-SR

Significantly Increases Timed Walk

Response

Protocol-Specified Primary Endpoint

93

429

0

10

20

30

40

50

60

Placebo (N=118) F-SR 10 mg bid(N=119)

Plt0001

Proportion

plusmn 95

Confidence

Limits

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Pain Presenting sx in 20 prevalence is 50 for moderate

to severe pain

Multiple potential causes

Inflammation

Neuropathic

Upper motor neuron damage

MSK

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Pain Types

PAIN

Neuropathic

Peripheral Central

Nociceptive

Musculoskeletal Visceral

Nicholson BD (2003)

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Pain Treatment Tailor based on most likely cause

MSK pain rx with acetaminophen NSAIDs local injection

physiotherapy and modalities

Neuropathic pain rx with TCAs and other antidepressants

anticonvulsants cannabinoids opioids

Severe cases consider intrathecal baclofen with morphine

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Adaptive Aides

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Adaptive aides Exercise

Equipment Braces

Canes

Crutches

Walkers

Wheelchairs

Adapted exercise equipment

water

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Dictus orthosis

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Exercise equipment

Motomed

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Uppertone Stim bike

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Intimacy

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Community programs AIM

Respiratory Health program

Yoga for persons with disabilities

MS exercise classes

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Breathing Space Yoga amp Wellness Centre

Fully Alive Chair Yoga - 6 week program on Weds

starting May 7 2-3pm

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

No paraplegia in a kayak

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Nutrition and MS Karen Gibson

Clinical Dietitian

Nova Scotia Rehabilitation Center

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

What to believe

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Be Wary

Promises of results

Cure

Magic ingredient

Available only through a site

If It Sounds too Good to be True It Is

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Some common diets suggested for MS

The Swank Diet

Studies were not blind or randomized and participant selection was biased

The MacDougal Diet

Testimonial with no clinical trials and very high doses of Vitamins and minerals can be toxic

Mind Your Mitochondrial Diet

Testimonial

Requesting money for research

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

What Have I got to Lose $$$

Can interfere with Medication prescribed by your Physician

Can be dangerous

Emotional Cost

The reality is success rates are low for controversial or untested therapies

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

ldquoThis matters to me because over the last 20 years I

have been encouraged to try so many expensive drugs

or treatments I would have done better to have a good

holiday It is hope that makes us grab at straws We

need facts not dreamsrdquo

Rita Baille has multiple sclerosis

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Accurate Information

Dietitianrsquos provide nutrition advice that is

based in science

Science never relies on just one study

Good science takes years

Not all studies are created equal

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

What we know

Nutrition needs of people with MS vary greatly

Age

Height

Weight

Mobility

No single nutrition plan meets the needs of all

individuals with MS

bull Co-Morbidities

bull Bowel and Bladder Issues

bull Swallowing Difficulties

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

A Healthy Diet Promotes Optimal

Health Includes servings from all 4 food groups

Includes a wide variety of foods

Is rich in nutrient dense foods

Includes bright coloured fruits and vegetables

Includes whole grain starches

Lean protein

Oily Fish

Limits total fat intake

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Calcium and Vitamin D

People with MS are at increased risk of falls

People with MS have a higher risk of low bone mineral density

1000-1500mg of calcium a day is recommended to maintain healthy bones

People with MS should supplement their diet with Vitamin D

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Calcium Content of food Food

250 ml glass of milk

1 ounce of hard cheese

frac34 c plain yogurt

frac12 c frozen yogurt

12 cottage cheese

frac34 cup baked beans

frac34 cup tofu

1 tbsp molasses

Calcium content (mg)

300

245

295

110

100

100

250

180

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Vitamin D Food

1 cup of milk

1 large egg yolk

1 tsp margarine

2 frac12 ounces pink salmon

2 frac12 ounces Atlantic salmon

2 frac12 ounces canned Mackerel

Vit D

100

60

25

350-500

180-240

220

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Vitamin D from Sunshine

5-30 minutes of exposure to sunshine between

1000 and 300 at least twice a week to the

facearms legs or back without sunscreen will

usually provide us with enough Vit D

Sunscreen with an SPF of 8 or more will block

UV rays

UVB rays do not penetrate glass

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Vitamin D supplementation

Vitamin D 800-2000 IU

Up to 4000 IU can be taken without risk

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Diet modifications can help manage

symptoms of MS

Weight Management

Bowel and bladder continence

Swallowing difficulties

Skin integrity

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Healthy Eating Start with Canadarsquos Food Guide

Choose a variety of nutritious foods

Donrsquot restrict your diet

Supplement with Vitamin D

MS Society of Canada

Ask for help

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Nutrition and Multiple

Sclerosis Dr Christine Short

Associate Professor

Dalhousie University Halifax

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

The Vitamin D Story

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Why vitamin D The geography of MS

Potent modulator of the immune system

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

The literature Over 100 articles published every year for the last 5

years on Vitamin D in MS

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Vitamin D and MS bull An international team of researchers led by Dr Alberto Ascherio of Harvard School of Public Health

set out to assess whether vitamin D status early in the disease process influences the long-term course of the disease

bull The study was published January 20 2013 in JAMA Neurology

bull 465 people with early-stage MS

bull A common marker of vitamin D statusmdashserum concentrations of 25-hydroxyvitamin D (25[OH]D)mdashwas measured at baseline (the onset of symptoms) and 6 12 and 24 months later

bull Participants were followed for 5 years with clinical assessments and MRI scans to monitor brain lesions and brain volume

bull The researchers found that higher serum 25(OH)D levels in the first 12 months predicted reduced MS activity and a slower rate of MS progression

bull By the end of the follow-up at 5 years participants with serum 25(OH)D concentrations of at least 50 nmolL (20-ngmL a moderate level) had significantly fewer new active lesions a slower increase in brain lesion volume lower loss of brain volume and lower disability

bull These results suggest that vitamin D has a protective effect on the disease process underlying MS

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Vitamin D and MS bull Studies are showing that

bull maintaining adequate levels of vitamin D may have a

protective effect and lower the risk of developing

multiple sclerosis (MS)

bull for people who already have MS vitamin D may lessen

the frequency and severity of their symptoms

bull Lower vitamin D levels found in people with more

severe disease

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

How Much 2000-4000 IU daily

Very large doses of vitamin D over an extended period

can result in toxicity

Signs and symptoms include nausea vomiting

constipation poor appetite weakness and weight loss

In addition vitamin D toxicity can lead to elevated

levels of calcium in your blood which can result in

kidney stones

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Other Vitamins Bitarafan S et al 2014

Our study support that lower magnesium and folate

diets are correlated with higher fatigue scores in MS

patients

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

MS and Osteoporosis

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

DEFINITION

ldquo A disease characterized by low bone mass and

microarchitectural deteriorations of bone tissue leading

to enhanced bone fragility and a consequent increase in

risk of fracturesrdquo

(National Institute of Health consensus conference 1994)

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Risk Factors Genetics (vitamin D receptor

allele)

Early menopause

Small build

Nuliparity

Cigarette smoking

Low calcium intake

Sedentary lifestyle (lack of weight bearing exercise disuse)

Chronic illness (inflammatory arthritis GI disorders)

Certain medications (Corticosteroids anticonvulsants)

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Osteoporosis can be Primary or

Secondary

Any age

Male or female

Corticosteroids

Long-term anticonvulsants

GI disease or procedure

Disuse

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Factors contributing to osteoporosis in the

rehabilitation population

Disuse osteoporosis

Increased bone resorption

Decreased bone production

Immobilization hypercalcemia

Insufficient 25-hydroxywitamin D

Hyperparathyroidism

Concomitant medications and disease

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Multiple Sclerosis Motor disturbances caused by progressive

pyramidal deficit and cerebellar dysfunction accompanied by ataxia with frequent falls and early decrease of physical activity are risk factors of osteoporosis in MS patients

Frequent need for steroids in managing relapsing remitting disease

Vitamin D

Khachanova et al 2006

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Multiple Sclerosis Thirty-one patients with MS and 30 matched healthy controls

BMD was measured using dual X-ray absorptiometry (DXA)

MS patients had significantly lower BMD at the lumbar spine (L2-L4) and femur trochanter compared to the matched controls

BMD of the lumbar spine was nearly 1 SD lower in MS patients compared with the healthy reference population (Z scores)

MS patients had significantly lower vitamin D levels (173 ngml vs 431 ngml P lt 0001) compared to controls and 19 patients (61) had a serum level of vitamin D that was less than 20 ngml

EDSS scores in the patients were inversely correlated with proximal femur BMD but not with spinal BMD

There was a negative correlation with the cumulative steroid dose and BMD only for femur trochanter BMD

Ozgocmen S et al 2005

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Multiple Sclerosis

Evaluated 38 patients with multiple sclerosis

Thirty-two (80) of patients had a reduced bone mass of either lumbar spine or the femoral neck

17 patients (425) had osteopenia and 15 patients (375) had osteoporosis

Twenty-one per cent (eight out of 38 patients) had vertebral rib or extremities fractures

EDSS was the important factor (P = 00017) associated with low BMD at the lumbar spine

No clear association between intravenous steroid therapy and BMD was evident in the multivariate analysis

Low levels of 25-hydroxy-vitamin-D were seen in 375 of patients

Weinstock-Guttman B 2004

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Bone Health in MS In a large US study examining over 1000000 hip

fractures the prevalence of MS in the population with

hip fracture was greater than twice that predicted and

MS patients suffered an acute fracture at an earlier

age

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Bone Health in Multiple Sclerosis

Treatment

Baseline bone density

Calcium

1000-1200mg per day

Diet +- supplement

Vitamin D

1000 to 2000 IU per day for bone health

Usually need a supplement to achieve this amount

Weight bearing exercise

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Conclusions Exercise and healthy diet are essential to good health and

wellbeing in all of us

This becomes even more important for people with chronic conditions like MS

There is a very large body of evidence supporting the value of exercise in MS and we now have excellent guidelines to help people with MS implement an exercise programs

Vitamin D is a critical nutrient for people with MS both for bone health but also for disease management

Osteoporosis is a common problem in people with MS Exercise prevents falls and helps maintain bone density Calcium and vitamin D are a critical part of your bone health program

Questions

Questions