Multiple Sclerose/M.S. Anhang 2
The central nervous system displays a level of structural differentiation that is unparalleled within the human body. The spatial gestalt of neuronal connections and their constancy over time are of crucial functional significance. In principle, the gestalt can remain intact throughout the course of life (over decades). This spatio-temporal structural fixity is associated with a great reduction in the vital regenerative power of the nervous system, even if (studies have shown in recent years) neuronal plasticity (particularly following traumas) is greater than was long assumed and certain stem cell populations retain the ability to replicate that mature nerve cells have lost.
At the moment it is still uncertain if these stem cells will prove to be of functional significance in the human organism. Be that as it may, an inner kinship is evident between the nervous system and mineral-colloidal formations in nature. If this is the "death pole" of the organism, then the opposite pole would be that of the blood, which remains in
a fluid state and manifests no constant spatial structure but provides for interconnectedness among all parts of the body and maintains the temperature relationships in the body. The cellular portion of the blood is subject to change (in part quite rapid) and the hematopoietic bone marrow exhibits the highest replicative capacity and regenerative power in the body. Active in the blood are forces with a chaotic, dissolving tendency as well as vital forces of a metabolic character. These gain predominance during inflammatory processes, leading to increased blood flow and (through the action of mediators) to structural dissolution. From an anthroposophical viewpoint, the nervous system and the blood represent opposite ends of a functional polarity; they work together in the organism but are not permitted to interpenetrate under conditions of health. The blood-brain barrier is one of the body's ways of ensuring this.
In the context of this polarity, the tendency of the nervous system towards degenerative pathologies can be understood as a further step towards reduced vitality, an expression of progressive "cooling" and rigidification. From the anthroposophical point of view, this goes parallel with a deficient permeation of the body by the actions
of the "I-organization," which physically realizes the inmost intentions of the individuality and manifests itself primarily through its structuring of the warmth relationships
in the body. On the other hand it is also obvious that inflammatory ("hot") diseases are capable of causing lasting structural and hence functional impairment of the nervous system. Within the central nervous system, the neurons are closer to the overall tendency of this organ system, while the glia fulfills not only structural but also primarily--metabolic and "nutritive" functions and is thus closer to the tendency of the blood. This view is supported by the fact that at least parts of the glia are of mesenchymal origin and even have precursor cells in the blood that have migrated into the realm of the nervous system. In tests aimed at developing reparative remyelinating therapies in multiple sclerosis, it was found that under certain conditions bone marrow cells can give rise to oligodendrocytes, the cells that are primarily damaged by this disease.
Multiple sclerosis is a common chronic disease of the central nervous system (incidence in Germany: 1 per 1000), with a highly individual course. Most persons affected ultimately suffer more or less severe functional impairments, but the spectrum of possible courses runs from completely reversible symptoms appearing after decades to severest impairments appearing within weeks, and even to almost immediate death. The disease can affect nearly all neurological systems of the CNS, causing sensory disturbances extending to total loss of sensation and blindness, motor disorders from paralysis to severe spasticity and ataxia requiring bedriddenness. It may also lead to impaired communication stemming from dysarthria due to affection of the cerebellum, as well as possibly affecting balance (dizziness), sexual function, and bladder and rectal function. Quite frequently patients are afflicted with fatigue and exhaustion, while neuropsychological impairments such as memory problems and emotional lability are also common. In the majority of cases separate episodes or attacks can be distinguished, between which–at least initially–there may be an absence of symptoms. However, there are also courses characterized by a gradual aggravation of symptoms, which may set in primarily or at any point in the course of the disease. There are a number of prognostic parameters, both clinical and paraclinical (based on MRI findings); however, in terms of both the disease dynamics and the type of functional failures to be expected, the individual course is difficult or impossible to predict. It is this uncertainty that patients experience as particularly tormenting; as one book title aptly puts it: "The only sure thing about this disease is its uncertainty." The debate continues today as to whether the different types of courses reflect distinct disease entities or not.
Evaluation of Existing Therapies
Cortisone therapy given during episodes is recognized as effective in shortening them (except in the special case of optic neuritis), but has no decisive positive influence on the longterm course. In recent years it has been found possible to improve the prognosis by use of beta interferon, glatiramer acetate (copolymer-1) and intravenous immunoglobulins. As far as is presently known, these therapies are not associated with the risk of inducing cancer and genetic damage or with significant cardiotoxicity, as was the case with undifferentiated immunosuppression using azathioprine or mitoxantrone; nevertheless, they too have significant side effects or risks. For example: Interferon preparations almost always cause flu-like symptoms and psychological side effects, some of them severe; glatiramer acetate produces local side effects at the point of injection; and with the administration of immunoglobulins derived from pooled blood of thousands of patients, the risk of infection can never be totally ruled out. For such reasons many patients discontinue prophylactic treatments after having begun them. Moreover, efficacy is limited: All procedures mentioned reduce the frequency of episodes and the progression of impairment by about 1/3, and the medicines are extremely expensive. Annual costs for any of them amount to more than 10.000 euros. Yet in spite of such drawbacks, these medicines can be of great value to some patients—alone or in combination with an anthroposophical treatment.
It is not surprising that many alternative approaches to treating this disease exist, many of them employing behavior modification alongside of pharmaceuticals.
In particular there are a number of dietary approaches, the most promising of these advocating a chiefly vegetarian diet (based on organic / biodynamic produce) that avoids products to which there is
an individual incompatibility as well as excessive amounts of easily accessible carbohydrates. This diet has also proven helpful in rheumatic ailments. A certain amount of fish, with its high proportion
of omega-3 fatty acids, may be beneficial in the diet. Some patients feel better generally, and in particular more alert and able to function, when their diet has an increased proportion of root vegetables (which are related to the nervous system in the anthroposophical understanding). Even with the means available to anthroposophical medicine, however, there has been no consistent success in producing reliable improvements, although in individual cases the course has clearly been influenced in a favorable direction and many patients have at least been permitted to experience a mitigation of their complaints. Some patients treated under an anthroposophical regime have experienced long-term absence of renewed symptoms, but in such an unpredictable disease this fact must be interpreted with caution. One basic reason why many patients turn to anthroposophical medicine in the course of their illness is related to its complexity: Characteristically there is an interpenetration of physical changes, depressed vitality and psychic symptoms, and the course is subject to influence by the physical, vital and mental/emotional factors. Unlike less complex systems of medicine, anthroposophical medicine takes account of the mutual influence of these levels and recognizes as central the patient's individuality with its intentions and goals in life. It is often emphasized by patients that they do not wish just
to be treated, but to be taken seriously as autonomous shapers of their path of healing and as active participants in their therapy. With its range of therapies (biographical and artistic approaches), anthroposophical medicine can meet these needs in a variety of ways. If our therapeutic potential is to improve regarding this disease, our still very incomplete understanding of it will have to grow.
Multiple sclerosis (or encephalomyelitis disseminata ) involves both inflammatory and degenerative aspects, as its two synonymous names imply.
In the acute episode alterations typical of inflammation (moderate rises in cell count and protein) are frequently found in the cerebrospinal fluid, and magnetic resonance imaging of fresh lesions generally reveals a disturbance of the blood-brain barrier, as is found in inflammatory processes. Pathoanatomically as well, lymphocyte infiltration points towards inflammatory processes in the acute episode.
In terms of the polarity presented above, one can speak of an excessive penetration of the blood dynamic into the nervous system. An at least partial collapse of the blood-brain barrier appears to be
a significant pathogenetic factor, the cause of which is still largely unclear. Simultaneously and subsequently, however, degenerative aspects such as axon destruction and glial scar formation appear as well. It is clear that autoimmune reactions to myelin, with which glia cells coat the axons, play a role here. The presence of myelin-activated lymphocyte clones alone, however, is not a sufficient precondition for the arising of MS; indeed, myelin antibodies may even be associated with a reparative aspect. Although the great majority of neurologists categorize MS as primarily inflammatory in nature, there are other voices that pinpoint its cause in an initial alienation of the myelin due to a "genuine weakness of the warmth organism." According to H. H. Vogel, this weakness is the result of a "psychological/psychosomatic process," an aspect of which is also considered in the studies of Treichler.
Outside the anthroposophical medical community too have been voices postulating recently, that in at least a portion of the patients primarily degenerative aspects are at play and that the inflammatory processes should rather be interpreted in terms of a clearing function. In this connection it is also noteworthy that inflammatory cells and mediators in the MS lesion are not solely harmful, but can directly induce reparative processes on neurons and glia. This could support the assumption of the anthroposophical physicians cited above that there is (at least in principle) an "upbuilding" aspect to inflammation in MS, while the primary pathology consists of a "degenerative" alteration within the brain. It follows from the facts we have cited that the overall aim must be to reestablish a healthy balance between degenerative and inflammatory disease tendencies. This goal, which has been stated in an important neurological journal, is completely in accordance with the anthroposophical view. This discussion indicates that a purely anti-inflammatory approach, taken to an extreme, could be counterproductive in the long term.
The actual cause of MS remains unclear. Certain genetic aspects are probable (moderately increased familial incidence can be proven, as well as somewhat higher incidence in specific HLA types), but they are significant only as dispositional factors and play no role in the great majority of cases. A range of external factors has been discussed as possible triggers of MS, but it has not been possible to make any sure and general claims about them. The involvement of (slow) viral infections could be neither proven nor excluded with certainty. In individual cases one has the impression that severe psychic stress, a flu infection or a vaccination might play a role in the first manifestation or in triggering an episode of MS.
One uncontested aspect is the geographical distribution of MS: It has been known for decades that the incidence of MS is related to latitude, standing at practically zero near the equator and rapidly increasing toward the poles. A report published in this journal some years back discussed this connection in terms of the different degrees of cold and light. Interestingly, since that time further analyses of the statistical material have revealed a closer relation to the geomagnetic latitude than to geographical. Additional findings (some of them still unpublished) corroborate an epidemiological connection that points towards an influence of the earth's magnetic field, which affects the actions of the particle stream emanating from the sun. It has long been accepted that an individual's place of dwelling at the time of puberty is decisive for the epidemiological risk of contracting MS. Mathematical analyses appear to indicate that alongside of this spatial aspect there is a significant temporal one (at least in girls, in whom the onset of sexual maturity is clearly marked by menarche): Onset of puberty during a period of maximum sunspot activity appears to be associated with increased risk of MS in relation to others born the same year (personal communication from J.Resch). Consideration of such geological and cosmological aspects of disease is a specific concern of anthroposophical medicine.
We must distinguish between treatment of acute episodes, attempts to influence the underlying pathology during symptom-free intervals (similar to attack prophylaxis in conventional medicine) and alleviation of symptoms that affect normal functioning.
Treatment of Attacks
As noted above, long-term positive effects with the conventional steroid treatment have been established only for optic neuritis. It is indisputable that sufficiently high doses of steroids shorten the duration of attacks. The conventional treatment for attacks consists of large intravenous doses of glucocorticoids (500 – 1,000 mg methylprednisolone per day) for 3 – 5 days. There is some dispute as to whether this should be tapered off with oral doses, but it would appear to be advisable for those patients who show rapid worsening of symptoms again after high-dose cortisone treatment.
This procedure is not free of side-effects. In most cases, patients have quality of life complaints. Particularly common are sleep disturbances, psychic alterations (even induction of psychosis at the extreme) and exacerbation of a (latent) infection. Some patients report becoming significantly more susceptible to illness following high-dose cortisone therapy. Over the long term, repeated administration of steroids is likely to result in descreased mineralization of the bones, which places these mostly young patients at risk for osteoporosis later on. High-dose steroid treatment always leads to at least temporary atrophy of the thymus. Furthermore, as we have indicated, the inflammatory element of the illness may well have meaningful aspects, and their complete suppression could also become problematic in the long term.
For all of these reasons, even from the viewpoint of conventional neurology it is inappropriate to treat each and every aggravation in an MS patient with steroids. As a rule, only "severe attacks" present an indication for treatment with corticoids. An attack is regarded as "severe" if it obviously and perceptibly handicaps the patient in normal daily activities, e.g. impairing the ability to walk or write.
Apart from dangerous situations (such as rapidly progressive transverse myelitis or vegetative crises), in all but a few cases it appears reasonable to pursue an alternative treatment approach, at least initially, and to consider a high dose of cortisone only when there is insufficient improvement. Generally a marked decrease in neurological symptoms should be achievable within one week; in case of further deterioration or stagnation a change in therapy should be considered no later than the end of the 2nd week, though in my experience this becomes necessary in no more than 15 % of cases.
Accompanying Therapy for Steroid Treatment
• Possible side effects of methylprednisolone infusion can be mitigated with Apis ex animale Gl 30 wa or Apis D30 w. One ampule can be added directly to the infusion or be injected daily s.c. If this is to be followed by a phase of oral administration, 5 drops of Apis D30 dil. w may be given daily before bed.
• Glandulae suprarenales comp. wa at a dose of 7 glob. in the morning supports kidney function that has been adversely affected by protracted steroid use and counteracts feelings of tiredness.
• Frequent states of agitation can be quite effectively calmed in most cases by adding one 10-ml ampule of Solum uliginosum comp. wa to the infusion. If necessary the preparation can also be injected separately i.v. Also for unrest and sleep disorders, embrocations with Lavandula Ol. aeth. 10 % w/wa are beneficial and effective.
Anthroposophical Treatment as Attack Therapy
In contrast to common practices, I believe that in the acute MS attack essential is maintaining rest, often bedrest for several days. One of the aims of this approach is to stabilize the distribution of warmth. Repeatedly it has led to a positive turn in the overall course of the illness. Any required thrombosis prophylaxis must be based on the individual case. The physician should be generous with certifying sick-leave and order household help as needed, since in a considerable portion of these patients acute overload of responsibilites must be regarded as favorable to attacks. Regarding external applications during the attack (for inner agitation) embrocations with Lavandula Ol. aeth.10% w/wa recommended (on the back region and affected extremities). Solum uliginosum comp. Oil. wa has a stronger warming action and is recommended for extreme weakness and loss of body warmth, as well as during regression of attack symptoms.
• During the attack, largely parenteral treatment is necessary. A basic scheme would consist of Apis ex animale Gl. D30 wa, Argentum metallicum praeparatum D30 w, Arnica e radice D20 wa as a daily s.c. injection. Depending on the neurological/topical diagnosis of the symptomatically most significant lesion, these remedies can be supplemented with a potentized Organ preparation in high potency (globuli D15 to D30). Their action is twofold, working against inflammation in the homologous region while guiding the action of other drugs used to that region. The organ preparations most frequently required are: medulla spinalis, cerebrum, regio motorica (or else the brain lobe preparations lobus frontalis, l. temporalis, l. parietalis und l. occipitalis), cerebellum (vertigo and ataxia of cerebellar origin), brain stem (for eye movement disorders and many symptoms in the domain of the brain nerves/nerve core—vertigo, oral dysesthesia, etc.), nervus opticus (for optic neuritis), etc.
• For highly pernicious attacks it may be advisable to alternate Argentum metallicum praeparatum with Stibium metallicum praeparatum D20 or D30 w.
With improvement the frequency of injections can be reduced. Also, lower potencies are to be preferred now, as their action promotes regeneration.
• Particularly at the onset of an attack, it may be best to stabilize the blood-brain barrier by employing, in addition to the organ preparation from the corresponding nerve tissue, a corresponding preparation of the supplying blood vessel such as Arteria cerebri media Gl D15 or D30 wa although the primary permeability is doubtless in the venous system.
• When the patient is under excessive stress and seems "psychologically thin-skinned," one may administer Solum uliginosum comp. (10-ml-Amp. wa) i.v. from 1x daily up to 3x weekly, depending on the intensity. When symptoms are pronounced, Amnion Gl D30 wa) is recommended in addition.
Anthroposophical Long-term Treatment
• A central element in a regime for positively influencing the course of the disease is oral administration of Stannum mellitum D20 w, 1 pea-sized portion in the evening, and Aurum comp. wa 5 glob. each morning and noon. The first of these remedies has a balancing action on the two opposing disease processes described earlier, and the second counteracts degeneration ("cooling") in the glial realm. While Stannum mellitum D20 is easily managed by patients, with Aurum comp. one must be aware that in rare cases a worsening of an existing depressive condition is possible, so that during an acute inflammatory phase one should consider Olibanum D6 (Staufen-Pharma) as an alternative. Frankincense (Olibanum), contained in potentized form in Aurum comp., is the combustible resin of the frankincense tree (Boswellia sacra), which grows in an inhospitable desert environment. In many respects the over-formative/deadening and energy-charged/metabolic processes and gestures of this plant reveal a kinship to the characteristic dynamic of multiple sclerosis. In substantial form, the boswellic acid found in frankincense preparations inhibits leukotriene formation. These inflammation mediators are likely a critical contributing factor to the collapse of the blood-brain barrier in the early phase of the development of an MS attack.
• Autoimmune reactions can be favorably influenced with Mercurius auratus D15 (Amp.Weleda) (ca. 1 x week s.c.). Symptoms such as nighttime sweating can also be an indication for this remedy.
• Berthierite D10, D30 Amp. w (1-2 x week) is recommended particularly in progressive disease conditions. The mineral on which this preparation is based unites the structuring action of antimony with the strengthening action of iron.
• When “psychological thin-skinnedness“ (see above) is an issue, when the demands of life become intolerable, and also when a change of weather has an unfavorable effect on the patient’s sense of well-being, Solum uliginosum comp. is recommended in the form of pillules as well, for regular oral administration (e. g. 5 glob. 3 x daily).
• Prudence is cautioned in the use of mistletoe therapy.
Simultaneously suffering from a form of cancer, high-dose mistletoe therapy (like any immune-stimulating treatment) can cause considerable aggravation in the course of the illness. In inflammatory phases of the disease as well, mistletoe should be used with caution, even in higher potencies. On the other hand, the use of potentized mistletoe can bring about a highly beneficial permeation with warmth, helping to „take possession of the body.“ Mistletoe is among those remedies that have the capacity to bring about a fundamental turning point in the course of illness. Its use is familiar in the realm of oncology, where the chief therapeutic aim is to re-connect the formative "higher members" with a body that is at the mercy of unrestrained vitality and cell growth. This connection is mediated essentially by warmth and by drawing in immune processes. Multiple sclerosis presents a different yet comparable situation: Organ domains that are threatening to fall out of the integrity of the whole need to be led back to the structuring and warming action of the individuality; immune processes that have become independent also need to be brought under the guidance of the individuality again. This process can be encouraged by potentized mistletoe preparations (since mistletoe preperations are legally authorized for oncological therapy, their neurological use would constitute an individual therapeutic experiment). Regarding host trees, the primary one will be Pini if light forces are required, Abietis if a permeation with warmth is needed, and Crataegi for harmonization and strengthening. I personally tend to use Iscucin Pini and Abietis in strength A, but Viscum Pini and Abietis in D30. Positive results are also reported with middle and higher potencies of Vysorel® (personal communication from V. Fintelmann).
• When the peak of an episode is past, and for attack prophylaxis, oil dispersion baths can play a very important role. A water vortex is generated in the bathtub using a glass apparatus attached to a fitting on the tub; a bath oil is allowed to flow into the middle of the vortex and undergoes ultra-fine dispersion by the shearing forces at work at the center of the vortex. It has been demonstrated that etheric oils dissolved in bath oil are better absorbed by the organism and that this form of bath (moderate temperature of 35 – 37°C) stimulates warmth production, resulting in a mild temperature rise during the night resting phase. While hot baths in multiple sclerosis typically lead to aggravation of symptoms as a consequence of a temporary decrease in nerve conduction velocity in demyelinized areas of the central nervous system, patients generally experience oil dispersions baths as beneficent (care should be taken that the patient does not get cold in the bath). In some circumstances the efficacy of the treatment can be further increased by brushing.
The following bath oils have proven most effective: Lavandula, Ol. aeth.10 % wa (unrest, sleeplessness and in some cases alleviation of spasticity), Solum-Öl wa (stabilization of body warmth, weather sensitivity and psychological sensitivity), Arnica e floribus W 5 % Ol. wa (stimulation of regenerative processes).
• For dysesthesias Dyskrasit D20 dil. w recommended
(5 drops 1 x daily); externally, Aconite Nerve Oil wa or Solum uliginosum comp. Oil. wa are beneficial. Particularly when paresthesias are associated with feeling of enlargement, Aranea ex animale D30 Amp. (various manufacturers) is indicated.
• Flaccid paralyses can be effectively treated with Skorodit D8 w (5 drops or 1 pea-sized portion 3 x daily).
• Spasticity often improves with Lathyrus sativus D6 (dil., w form or standard form, e.g. DHU). Initial dose is 5 drops 3 x daily, which may be increased if action is insufficient; in rare cases of intial worsening, D12 potency should be given (2 x daily).
• Involuntary twitching or jerking that primarily affect ability to fall asleep can be alleviated with Valeriana c. Zinco wa D6 or D12 (5 glob. before bed) or with Zincum met. praep. D20 w (5 drops before bed).
• For bulbar symptoms Naja D30 Amp. w is recommended, 1 ampule 2 x weekly s.c. (e.g. in back of neck).
• Fatigue and exhaustion (caused by steroid treatment) can be alleviated with Glandulae suprarenales comp. Glob. Wa (5 glob. morning and noon); in other cases
Levico comp. Glob. wa (at the same dose) or Prunus spinosa e summit. D6 Glob. are recommended.
• The most common side effect of glatiramer acetate (relatively unproblematic on the whole) is skin reactions, which may include severe itching over a wide area.
This side effect can be alleviated with amazing efficacy by having a potentized formulation of the drug made (at D6) and giving the patient 3 to 5 drops of it before injection.
Regarding the long-term course of the illness, it is important for patients to develop self-observation skills and become acquainted with their own limits. Sometimes psychotherapy helps in adjusting to life with the illness and incorporating biographically significant aspects. Curative eurythmy, alongside of any necessary physiotherapy or ergotherapy, provides a significant support for most patients; often it is sufficient to do it in blocks or alternately with the other therapies. Most patients find rhythmic massage greatly enhances their sense of well-being; it also helps harmoniously integrate areas of the body that have fallen out of the organismic whole because of dysesthesias and spasticity. Craniosacral therapy can also be beneficial, though this depends on finding a well-trained and prudent therapist, since the procedure is not risk-free (possible worsening of symptoms and mobilization of psychic traumas which then require skilled professional intervention). It is often particularly helpful for patients suffering from a protracted Lhermitte’s syndrome (tingling paresthesias on neck flexion), but also for those suffering from vertigo and tonus irregularities.
Many MS patients are also helped by painting therapy, which can have a pyschologically liberating and stabilizing effect. Experienced painting therapists have observed that pictures painted by MS patients often show a separation into „cool“ and „hot“ regions, which would correspond to the two opposing disease processes. An art-therapeutic regime that strives to restore equilibrium may well influence the disease process itself, but this remains to be corroborated by further observation.
Overall, anthropsophical treatment for multiple sclerosis is satisfying. Many patients experience it as noticeably beneficial; they sense that it is not simply a manipulation or suppression of physical processes but that it pursues a directly healing approach. For all the repeated, clearly observable benefits that medicinal therapy can have, however, ultimately the crucial dimension—overcoming the disease—lives within the patients as they deal with the disease, seek meaning in it and order their lives accordingly. Many patients gain the deep respect of their physician in this process; he too can learn from them. No less crucial for many patients with this life-accompanying disease is the religious dimension. In this regard pastoral-medical collaboration can be of great significance. Altogether, in a disease which affects so many aspects of the human being and can also be positively influenced from so many different directions, close collaboration is indispensible among all those acting therapeutically on behalf of the patient.