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Supplements The Role of Brain Preservation in the Management of Multiple Sclerosis

Comorbidities Management and Lifestyle Modification in Patients With Multiple Sclerosis

Diminished visual and verbal memory, executive functions, and processing speed have been observed in patients with MS who have sleep disturbances and apnea.22 Effective treatment may offer new opportunities to improve cognitive functioning in this patient population.22 Tobacco use also has also been linked to cognition in those with MS. The results of one study showed that 29.2% of nonsmokers and 60% of heavy smokers, both with MS, had cognitive impairment.23

Several cognitive exercises have been shown to improve learning and memory in patients with MS. A study that examined the efficacy of the modified Story Memory Technique (mSMT) to improve learning and memory abilities in patients with MS consisted of 10-session behavioral interventions, teaching context and imagery to facilitate learning. The double-blind, placebo-controlled, randomized clinical trial included 86 patients with MS, separated into either the treatment group (n = 41) or the placebo control group (n = 45). Patients completed questionnaires assessing everyday memory for the baseline neuropsychological assessment, had a repeat assessment immediately post treatment, and had a long-term follow-up assessment 6 months after treatment. After therapy, patients in the treatment group were assigned to a booster session or a non–booster session group to examine the efficacy of monthly booster sessions in facilitating treatment effects over time. Results showed that the treatment group demonstrated a significantly improved learning slope relative to the placebo group post treatment. It was determined that the mSMT has an impact on improving learning and memory in patients with MS.24

Cognitive leisure activities (eg, reading) influence greater brain growth, vocabulary knowledge, and involvement in hobbies, all of which are linked to increased ability to cope with MS and diminished cognitive impairment.20 In a study examining maximal lifetime brain volume and disease-related cognitive impairment, researchers analyzed the relationship of cognitive reserve through lifestyle changes in 62 patients with relapsing-remitting or secondary-progressive MS. Investigators also evaluated cognitive efficiency and memory. Higher education (P = .03) and increased leisure (P = .001) were associated with better cognition. Intellectual leisure activities included reading, art, writing, playing instruments, and structured games.25 The investigators concluded that patients may be able to preserve brain reserve and protect cognitive efficiency through disease-modifying therapies and being proactive about their brain health.25

The Role of Lifestyle Interventions in Management

Given the impact of MS on cognition and the growing emphasis on the role of comorbid conditions, brain preservation and comprehensive brain health via lifestyle interventions, in concert with cognitive exercises, are increasingly recognized as important factors in the broader management of patients with MS. Although data are limited, preventing, minimizing, and appropriately managing comorbidities can potentially help to reduce their negative affect on MS and optimize outcomes.2,7,9,13

Lifestyle interventions potentially improve QOL in patients with MS.26 For effective management of comorbidities through lifestyle, patients must be willing to practice healthy habits, such as reducing/eliminating tobacco and alcohol use, maintaining a healthy weight from eating a healthy diet and increasing physical activity, lowering weight and BMI, increasing sleep, and reducing stress.26,27 Dietary habits have been shown to affect inflammation. For instance, red meat has been shown to enhance inflammation, while omega 3 polyunsaturated fatty acids diminish inflammation. Patients should be encouraged to focus on and remedy lifestyle risk factors that can negatively affect cognitive brain function and vascular effects.26

In addition to adapting lifestyle changes to impact the outcomes of certain comorbidities, cardiorespiratory fitness has been studied to uncover ways to improve volumes of deep gray matter involved in cognitive and motor functions in patients with MS.28 In one study, investigators evaluated the impact of cardiorespiratory fitness on 35 patients with clinically definite MS who were relapse-free for 30 days, aged 18 to 64 years, able to walk with or without assistance, had the willingness and ability to complete self-assessments, and had a physician’s approval for exercise. The mean disease duration was 11.4 years (SD = 7.5).28 Physical activity regarding cardiorespiratory fitness was assessed and accommodated if a patient had a disability (eg, seated stepper), while brain volumes were measured by oxygen consumption and MRI. The results showed that cardiorespiratory fitness is associated with deep gray matter volumes and has an impact on cognitive and motor function in patients with MS.28

Vitamin D supplementation could also improve cognitive performance. In a study analyzing the relationship between vitamin D levels and cognitive impairment, investigators examined 88 patients with MS who had a vitamin D deficiency compared with those who had sufficient levels of vitamin D. The change in cognitive performance was examined after 3 months of a vitamin D3 oral replacement. Cognitive performance was tested at baseline and follow-up using the Montreal Cognitive Assessment, Stroop, Symbol Digit Modalities, and the Brief Visuospatial Memory tests. Results showed that the vitamin D3 replacement improved cognitive performances in patients with MS after 3 months, resulting in a significant betterment in QOL.29

In addition to diet and physical well-being, lifestyle interventions in individuals with MS should encompass emotional wellness.10 For instance, many patients may not know with how to deal with such psychological comorbidities as stress, anxiety, fatigue, and depression. Meditation can serve as an adjunct to treatment, as it can reduce stress levels, improve a patient’s well-being and QOL, and decrease morbidity.30 A mixed methodology study that included participants attending an MS workshop for patients found that 25% of attendees practiced relaxation and meditation activities in the past 12 months. Attendees of the workshop found that meditation and relaxation were either somewhat helpful or extremely helpful at improving MS symptoms. They reported improved sleep, reduced spasticity, eased muscle tension, and increased well-being.30,31

Mindfulness-based interventions, such as mindful breathing and movement, may also benefit QOL and mental health in patients with relapsing-remitting MS, according to a global review of randomized controlled trials. All studies included in the global review reported on QOL, mental health, physical, and psychosocial measures that had a 3- to 6-month follow-up period.32 Mindfulness practices were shown to benefit QOL, mental health, and certain aspects of physical health in patients with MS, but given the limitations of the data, investigators noted that additional high-quality studies are needed to assess the benefits of mindfulness further.32


As the integral role of comorbidities in MS disease course and the resulting disabilities continue to be elucidated, management strategies increasingly emphasize comprehensive brain health and preservation. Although limited, data supporting the therapeutic potential of lifestyle interventions demonstrate the potential of wellness efforts to reduce disease inflammation, relapse, and symptoms. As the treatment landscape continues to expand with the development of new disease-modifying therapies, a healthy lifestyle—ranging from diet and fitness, to mindfulness and medication—is an important adjunct to optimal therapeutic regimens.

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