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    You are here : Home » About MS » Causes of MS » Trauma and MS

    Trauma and MS

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    ConcussionIs there a connection between Trauma and MS?

    A Review of the Literature of Dr D Gay & Sylvia Brown

    Patients with MS frequently relate the onset of the disease or a deterioration in symptoms to a traumatic episode in their lives. This may be a physical injury such as a blow to the head with concussion, or a time of excessive stress such as a divorce or bereavement. Less frequently I am asked if a case could be made out in the law courts that an accident caused MS or brought on an exacerbation that would not otherwise have happened.

    I have only heard of one success in a case of this kind - that of Mr Dingley in 1996, a former police officer aged 31 at trial, who was awarded £547,250.00 compensation, after a Scottish High Court judge accepted evidence that his condition had been triggered by whiplash injuries sustained in a road traffic accident. The judgment was successfully appealed to the Scottish Court of Session. Mr Dingley appealed further, but sadly, on 9th March 2000, the House of Lords upheld the appeal court's decision.

    No one knows what causes MS. The received wisdom is that a genetic factor is involved. It is common ground that trauma to the central nervous system (CNS) cannot cause it. The controversy is whether those genetically at risk (potential demyelinators) can be rendered symptomatic by trauma to the CNS. i.e. whether trauma can trigger MS. In the Dingley case the claimants relied principally upon the evidence of two senior neurologists: Dr Charles Poser (Harvard Medical School) and Professor Peter Behan (University of Glasgow). They stated that an injury such as a whiplash injury to the neck can produce a temporary alteration or breakdown in the blood brain barrier (BBB), the organic mechanism separating the CNS from the blood stream whose function is to allow essential nutrients to pass from the blood to the brain.

    The hypothesis is that when the BBB is opened by such an injury, deranged cells known as T-lymphocytes are permitted free passage from the blood stream into the CNS where they contribute to the development of MS plaques. Hence, a whiplash injury may trigger MS in an asymptomatic potential demyelinator. Although it is generally accepted that an injury to the CNS does produce an alteration in the BBB, it is hotly disputed that this is associated with the development of MS symptoms. That there could be a link between trauma and multiple sclerosis is a recurring theme in the literature going back as far as the great neurologist Charcot who defined MS in the mid 1860's. The deeply experienced Harvard neurologist, Charles Poser, made out a strong theoretical case for trauma to the head or central nervous system as a potential trigger of exacerbations by this damage to the blood-brain barrier. Poser did not believe that trauma is the cause of MS but that it activates an underlying and possibly inherited defect in the small blood vessels of the brain.

    Studies to investigate the role of trauma in MS are scattered throughout the literature. Dawson, in his celebrated study of 1916, cites cases where “the association of trauma and the onset of the disease was a very close and striking one”. The best contemporary review of the evidence may be found in the 1991 edition of McAlpine’s “Multiple Sclerosis”. Professor Bryan Matthews concludes that the evidence is far from convincing and suffers from a lack of controlled studies in which patients are followed up after diagnosis (prospective study). Where controlled follow-up has been undertaken, however, no difference has been found in the incidence of trauma in MS persons and in their controls. It has to be admitted that individual cases where trauma is closely followed by an exacerbation of MS appear in numerous reports, such as those of Keschner and Burke & Cheshire, but when controlled comparisons are carefully made these tantalising clues appear to occur no more frequently than would be expected by chance.

    A large study of records from 1905 to 1991 on trauma and MS was undertaken at the Mayo Clinic (Siva, A et al, Neurology 43:1878-82), on approximately 100,000 inhabitants of Olmsted County in the North Eastern USA. What is impressive about this study is that it appears to be complete for the population and includes house visits as well as hospital admissions. There were 225 MS cases and 819 cases of head injury between the ages of 10 and 50 when MS could have developed. Only two of the 819 developed MS (.024%) and none of the people with MS had head injuries after the onset of the disease. The researchers compared the period before any trauma with the period following trauma and found that MS was no more active before than after fractures or other injuries. They conclude that head injuries cannot be incriminated for MS and injuries in general are most unlikely to be involved in any way.

    These impressive results agree with follow up studies by Sibley (Sibley, WA et al, Journal of Neurology, Neurosurgery, and Psychiatry 54:584-9) which failed to show any association between trauma in general and exacerbations of MS. If there is any doubt remaining, more direct evidence may come from those MS people who are currently being followed up using magnetic resonance imaging(MRI). If a bang on the head can disrupt the blood-brain barrier and it can be shown that a MS lesion develops around the site of the damage we may hear more on the subject in the future.

    However, it should be noted that MS patients who happen later to develop other diseases of the brain such as strokes or cancers in which the blood-brain barrier is severely disrupted, do not develop MS plaques at these damaged sites. It is therefore extremely unlikely that trauma which cannot produce anything like the degree of brain damage found in these other common conditions can cause or exacerbate multiple sclerosis. So for the time being at least, those who develop MS following injury are unlikely to be able to establish on the balance of probabilities that the onset of their disease was related to their accident.

    Both studies did show, however, that more traumatic events occur among people with MS than in the healthy control group. Many of these traumas were caused by symptoms such as lack of coordination, impaired balance, abnormalities of gait or visual impairment. These events occurred, however, as a result of MS symptoms and were not causal factors in the disease.

    A recently published case study, however has shown that correction of upper neck injuries may reverse the progression of MS. The research was performed by Erin Elster D.C, an upper cervical chiropractor specialist working in Boulder, Colorado. He corrected chronic upper neck injuries in an MS patient, which may have stimulated a reversal of his MS symptoms.

    "According to medical research, head and neck injuries have long been considered a cause of Multiple Sclerosis", says Dr Elster. "But this is the first research to show that correction of those injuries can have dramatic effects on reversing MS." This report appears in the Journal of Vertebral Subluxation Research (JVSR).

    It has also been reported by Klaus Fassbender (Arch Neurol. 1998;55:66-72 January 1998) that people with MS are more prone to  anxiety and depression and these affective and NeuroEndocrine disorders have been related to inflammatory disease activity, though interestingly not to the degree of disability. This supports the hypothosis that the anxiety and depression are causally related to brain injury. Hence patients with MS, may become more anxious and depressed as a result of MS, but this appears not a precipitating factor in the condition.

    So when it comes down to proving a link between physical trauma and MS the evidence to date is still limited and you’d have your work cut-out proving this irrefutably in a court of law. However in spite of this there is substantial amount of anecdotal evidence from people with MS, whose onset of symptoms coincided with a traumatic event. When it comes down to deciding whether emotional stress can trigger MS, though there is some quite substantial evidence of a link, the scientific data is again somewhat contradictory. In a study conducted by Warren S, Greenhill S, Warren KG (J Chronic Dis 1982;35(11):821-31), significantly more MS patients than controls reported that they were under unusual stress in the 2 yr period prior to onset age. In a more recent, however, study by Heesen C (Brain Behav Immun 2002 Jun;16(3):282-7 ), an altered neural immune signalling in relapsing-remitting MS patients during acute experimental stress could not be proven for the parameters analysed.

    In a further study by Ackerman KD, at the University of Pittsburgh, Pennsylvania (J NeuroImmunol (Psychosom Med 1998 Jul-Aug;60(4):484-91), results favoured the hypothesis that MS patients do not differ in stress response from normal controls, but that psychological stress may enhance cellular immune responses that would be potentially harmful to MS patients. Added to this it has been recently reported that acute stress increases the permeability of the blood-brain-barrier through activation brain mast cells [Esposito et al., Brain Res 2001 Jan 5;888(1):117-127]. Disruption of the blood-brain-barrier is important in the development of MS as the breakdown of the barrier precedes all clinical findings. This breakdown allows activated immune cells from the bloodstream to enter the brain and spinal cord, which is an initial event in MS activity.

    There is some evidence that relapsing-remitting MS attacks may be correlated with certain types of acute stressful episodes. Stress typically activates the brain through the release of a corticotropin-releasing hormone. However, acute stress also has inflammatory effects that appear to be mediated through the activation of mast cells [Ref: MS Highlights, Issue 2, Vol.4-2001.].

    Also, researcher David Mohr PhD from the University of California at San Francisco, has reported an association between stress and the development of new lesions (damaged areas) in the brains of individuals with Multiple Sclerosis. So it does look likely that stress can have a detrimental affect on a person with MS.

    Many MS patients have correlated their exacerbations with major stressful events such as divorce, car accidents or major illnesses or deaths in a family preceding months to their attack. What is very clear is that physically or emotionally traumatic or stressful events make people with MS feel worse anyway and result in at the very least their perceiving a magnification in MS symptoms. So what is the solution?

    Well obviously it is not always possible to avoid traumas, such as accidents or bereavements, but we can avoid or at least learn how to better manage stress in our daily lives. Stress in not really the problem here. The problem is how you perceive or handle the stress. How you choose to handle life or react is in your hands and is up to no one else. Maybe you decide that your job is too stressful and you are paying a price putting your health on the line. In that case maybe it is time to change your job, or cut-back on your hours. But if you love your job and it partly defines who you are as a person then it may well help keep you going in the long run.

    Some people seem to thrive on stress. Only you can decide ultimately what you can handle and what is best for you. We may not always be in charge of everything life throws at us but most of the time we do have a choice in how we react and how we deal with these events. You have MS so be kind to yourself, give yourself time to get over any traumatic events or adjustments in your life and try not to stress out over what at the end of the day may not be all that important in the picture. After all what matters most is your health and happiness.

    Further Information

  • Head and neck injuries
  • Views on positive thinking
  • How others have dealt with stress in their lives 

    © Multiple Sclerosis Resource Centre (MSRC)

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