Let the Sun Shine In

Multiple Sclerosis, Vitamin D, and Massage Therapy

By Ruth Werner
[Pathology Perspectives]

MS is one of the most common autoimmune diseases in the United States. Some recent discoveries may explain one of the biggest mysteries about MS, and inform our work as we consider both anecdotal and clinical findings about the role of massage for this condition.

MS Basics

MS is a progressive degenerative disease of the central nervous system (CNS). It is now widely understood to be an autoimmune disease, but as recently as the early ’90s many specialists didn’t agree on its pathophysiology. It was treated with anything and everything—from massive doses of vitamin B to hyperbaric oxygen chambers. Now, experts agree that MS occurs when various immune system cells, antibodies, and destructive cytokines mistakenly attack the myelin that surrounds neuronal fibers in the CNS.

Readers may remember that myelin is a waxy substance that helps to speed and insulate electrochemical nerve transmissions along neuron fibers (“MS: Easing Symptoms with Informed Massage,” November/December 2012, page 56). The myelin in the CNS is produced by glial cells called oligodendrocytes. When these cells are under attack, they multiply in an attempt to repair the damage, but eventually they may fail. At this point, myelin in the brain and spinal cord is replaced with scar tissue in numerous patchy areas—hence, “multiple sclerosis.” Electrical impulses cannot travel efficiently along neurons with faulty myelin; essentially they short-circuit. If flares repeat in the same areas, damage may penetrate through to affect the nerve tissue directly. In this case, lost function is probably permanent.

The consequences of MS depend on what part of the CNS is under attack. Weakness, changes in sensation, optic neuritis, urinary and sexual dysfunction, sensitivity to heat, and overwhelming fatigue are common. Loss of motor control with painful spasms, cognitive changes, and motor and/or sensory paralysis are all possibilities. For this reason, MS in one person can look extremely different from MS in another person, and the disease is sometimes called the “great imitator.”

Its identification as an autoimmune disease has led to much more consistent and successful treatment options for patients than used to be available. A class of drugs called DMAMS (disease-modifying agents for MS) includes substances that can shorten flares, prolong remission, and quell immune-system activity. Steroidal anti-inflammatories may also be used, with cautions for dangerous side effects. Additional drugs can help with cognitive changes, fatigue, urinary symptoms, and other problems. All in all, the pharmacological treatment options for MS are better than they ever have been, but no treatment is successful for all patients, and no treatment can permanently correct the immune system activity that leads to the damage in the first place.

MS, UV Radiation, and Vitamin D

The geographic distribution of MS has always suggested that this disease is most common in Caucasian populations living far from the equator. Canada, the United States, the United Kingdom, and Scandinavia show the highest concentrations of people with this condition. 

This observation has led to the hypothesis that MS is mainly a disease of genetic predisposition, with prevalence among Northern Europeans, and certainly that appears to be a major factor. But another important factor in the development and the severity of MS turns out to be a lack of exposure to sunlight, especially during childhood. The exact link of how exposure to ultraviolet (UV) radiation, or more specifically the lack thereof, might lead to this condition has been a mystery, but some recent findings have begun to shine a light on this question.

One of the things that happens when we are exposed to the UV rays in sunlight is that our bodies manufacture vitamin D. This fat-soluble vitamin is important for bone health, but it also influences immune system activity and can reduce inflammation. Vitamin D has been investigated as a protector from several diseases with varying conclusions, but the data on vitamin D and MS is relatively consistent and positive: people diagnosed with MS who have higher levels of serum vitamin D have fewer flares, fewer lesions identified by MRI, and a lower risk of disability than others. Further, people with low levels of vitamin D had a risk of developing MS more than twice as high as people with higher levels.1 (For more information on vitamin D levels, see Vitamin D—How Much is Enough?, page 47.)

MS and Massage

Massage is a popular intervention for MS patients; about one-third include massage in their treatment strategies.2 The research about the usefulness of massage for MS symptoms is mixed, but mostly positive. One study investigated whether receiving massage would allow MS patients to walk more quickly and report an improved quality of life (QoL). They found that while the walking speed and QoL reports didn’t change, patients reported an improved “personal health rating” that fell when massage was withheld. They concluded that massage is a noninvasive, safe, well-received intervention that is effective for controlling pain and managing stress.3 In a study that used craniosacral therapy for MS patients, QoL scores did improve, along with urinary tract symptoms.4

In an MS study comparing several different interventions, 10 patients out of 30 were assigned to a massage clinic while the others received other therapies.5 Patients received massage once a week for 12 weeks. The therapists found that MS patients did not like pressure that was too light or too deep. They also did not like friction or rubbing against the skin layer. Massage use with even rhythms and balancing strokes with no sudden tempo changes was critical. By week four, the patients who used walkers were fully ambulatory. By week 10, the patients who used wheelchairs were fully ambulatory. After the study was concluded, at least two participants who did not continue receiving massage reverted back to wheelchair use. Unfortunately, the study was focused on different outcomes and other interventions, so these remarkable findings have never been reported.

Many MS patients experience severe constipation, as nerve signals to the viscera and sphincters can be impeded. Abdominal massage, which can be taught to be self-administered, has been shown to be effective in managing constipation, and this can have a positive impact not only for the patients, but for the patients’ caregivers.6

A study comparing traditional foot reflexology to a sham treatment and to a control group to look for ways to manage the pain associated with MS found that both of the foot treatment groups experienced statistically significant improvements in pain as compared to the control group.7

These studies, along with a stack of clinical anecdotes, suggest that massage has more benefits to offer MS patients than risks, though those risks are not negligible. MS patients can experience numbness, which means they are potentially vulnerable to tissue damage. Very advanced cases may interfere with verbal communication, in which case the massage therapist must be extremely sensitive to nonverbal signals. MS medications can interfere with immune system function and the inflammatory process. And, in general, although the reasons for this are not clearly understood, many MS patients appear to be highly sensitive to rapid changes in their environment. In the context of a massage, this means MS patients may not tolerate a rapid move from hot to cold or vice versa, and many of them have negative reactions—including painful spasms—to massage that is too fast, too deep, too jumpy, or in any way unpredictable. 

Right now about 250,000–350,000 people in the United States are living with MS. Although massage therapy has much to offer this population, most MS patients don’t get massage on a regular basis. This is an example of where a collection of well-executed case reports demonstrating specific information about how massage impacts the quality of life of those with MS could make a big difference—not only for our profession, but, more importantly, for all those people who are waiting for our skills. Do you work with MS patients? Consider sharing your experiences with your peers by writing a case report. For more information, visit www.massagetherapyfoundation.org/casereports. Don’t know how to write a case report? Check out ABMP’s webinar series “Writing a Case Report,” available in the Online Education Center at www.abmp.com. 


1. Science Daily, “Low Vitamin D Levels Linked to More Severe Multiple Sclerosis Symptoms,” accessed April 2013,
www.sciencedaily.com/releases/2012/10/121002091755.htm; Medscape, “More Evidence that Vitamin D May Protect Against MS,” accessed April 2013, www.medscape.com/viewarticle/774749; A. Solomon, “Multiple Sclerosis and Vitamin D,” Current Neurology and Neuroscience Reports 10, no. 5 (2010): 389–96.

2. R.A. Marrie et al., “Predictors of Alternative Medicine Use by Multiple Sclerosis Patients,” Multiple Sclerosis Journal 9, no. 5 (2003): 461–6.

3. B. Schroeder et al., “The Effects of Massage Therapy on Multiple Sclerosis Patients,” BMC Complementary and Alternative Medicine 12, S1 (2012): P225. 

4. G. Raviv et al., “Effect of Craniosacral Therapy on Lower Urinary Tract Signs and Symptoms in Multiple Sclerosis,” Complementary Therapies in Clinical Practice 15, no. 2 (2009): 72–5. 

5. K. Khoo et al., “Cognitive Therapy for Multiple Sclerosis: A Preliminary Study,” Alternative Therapies in Health and Medicine 2, no. 5 (1996): 70–4. 

6. D. McClurg et al., “Abdominal Massage for the Alleviation of Constipation Symptoms in People with Multiple Sclerosis: A Randomized Controlled Feasibility Study,” Multiple Sclerosis Journal 17, no. 2 (2011): 223–33. 

7. C.M. Hughes et al., “Reflexology for the Treatment of Pain in People with Multiple Sclerosis: A Double-Blinded Randomized Sham-Controlled Clinical Trial,” Multiple Sclerosis Journal 15, no. 11 (2009): 1,329–38.


Carrie began to lose bladder control at age 27. A year of doctor visits with a general practitioner, OB-GYN, urologist, and neurologist eventually led to her diagnosis of multiple sclerosis (MS). By age 35, she needed crutches to get around; by age 40, she was confined to a wheelchair. Carrie is in her mid-50s now. Her condition is stable, but the nerve damage is permanent; she won’t walk again.


Tricia came home from a family vacation with an unusual, new, nervy sensation in the soles of both feet. Within days, this 32-year-old mother of five young children could no longer walk and had to move around her house by crawling on her hands and knees. Her diagnosis was fast and dire: malignant MS. In the hospital, she was instructed to go home and put her affairs in order. Fifteen years later, her MS is under control, but she lives in fear of permanent blindness.


Vitamin D—How Much is Enough? 

The recommended daily allowance for vitamin D in the United States is a bit complex, because several variables affect its levels. The most accepted recommendation is 600 international units of vitamin D per day, but this does not differentiate between dietary sources, supplemental sources, and the vitamin D stimulated by sun exposure, which varies according to cloud cover, latitude, melanin level, and season. Cod liver oil, salmon, sardines, and swordfish may be the most efficient nutritional sources, but margarine, milk, some yogurt, and many breakfast cereals are fortified with vitamin D. 

Fortunately, the body can store this vitamin so that those living in northern climates can essentially stock up on vitamin D during the long days of spring and summer—but only if the skin is exposed to UV radiation. The use of sunscreen to prevent skin cancer has been seen to have an unexpected side effect, inhibiting the manufacture of vitamin D. 



Client “MJ” was suicidal, reported constant pain, and was unable to work or drive. His massage therapist delivered full-body massage with light pressure and lymphatic drainage, and eventually incorporated fascial release and abdominal massage. MJ started with two sessions per week and eventually pared back to twice a month. Within two weeks of starting massage, MJ was able to return to work. His self-report: “I’m fine as frog fur.”



Ascherio, A. et al. “Vitamin D and Multiple Sclerosis.” The Lancet Neurology 9, no. 6 (2010): 555.

National Institutes of Health. “Dietary Supplement Fact Sheet: Vitamin D.” Accessed April 2013.

Nusrat, S. et al. “Anorectal Dysfunction in Multiple Sclerosis: A Systematic Review.” ISRN Neurology 2012. Accessed April 2013. www.ncbi.nlm.nih.gov/pmc/articles/PMC3414061.

Science Daily. “Vitamin D Deficiency Related to Increased Inflammation in Healthy Women.” Accessed April 2013. www.sciencedaily.com/releases/2009/04/090408140208.htm.

The Wall Street Journal. “Multiple Sclerosis Linked to Vitamin D Levels, Study Says.” Accessed April 2013. http://online.wsj.com/article/SB10001424127887323353204578129280745162230.html.

Ruth Werner is a writer and educator approved by the National Certification Board for Therapeutic Massage & Bodywork as a provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2012), now in its fifth edition, which is used in massage schools worldwide. Contact her at www.ruthwerner.com or wernerworkshops@ruthwerner.com.

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