Multiple Sclerosis

Multiple Sclerosis: Overview

Alternative Names: MS.

Multiple Sclerosis is an unpredictable disease of the nervous system which manifests itself primarily through disorders in mobility.  It is associated with a variety of other symptoms and complications.  The most important fact about multiple sclerosis is its unpredictability and its uncertainty.  There are very few certainties to be found anywhere in any aspect of this disease. Multiple sclerosis is a demyelinating disease of the white matter of the central nervous system.  Gray matter consists primarily of nerve cells.  Axons (nerve fibers) are the connections between the cell body and the muscles, sensory organs, and primary organs such as the heart.  These nerve cells are the communication system both within the central nervous system and between it and the rest of the body.  Axons are sheathed in myelin, a white substance (hence the term "white matter") that insulates them and speeds transmission of impulses along the cell fibers.  Electrical impulses move along the nerve fiber to the synapse (the connection point between cells) to the next nerve cell.

Incidence; Causes and Development

MS is the most common demyelinating disease of the central nervous system.  In the United States alone, there are at least 250,000 cases.  For reasons that remain unclear, it is more prevalent in northern temperate zones and affects noticeably more women than men.  The average age of onset is thirty years.

The lesions or plaques of multiple sclerosis are areas of tissue damage arising from inflammation, which occurs when white blood cells and fluid accumulate around blood vessels.  This inflammation causes destruction of myelin.  After the fragments are cleared away, a scar is formed in the area which is the lesion, or area of demyelinization.  These lesions impede conduction of signals by blocking or slowing communication, either completely or partially and from time to time.  The process can be thought of as similar to an electrical short circuit.  The symptoms of multiple sclerosis result from this loss in signal conduction.

Studies indicate that an environmental factor, perhaps exposure to a virus, when combined with a genetic predisposition to the disease, may well dictate occurrence of the disease.  MS is not a genetically transmitted disease; it may be an autoimmune disease, with some part of the body attacking itself.

Signs and Symptoms

Symptoms may appear very rapidly, within minutes or days, or very slowly, over a period of weeks.  They may be very transient and come and go rapidly.  New symptoms may accumulate; old symptoms may reappear and/or intensify.

Symptoms of MS vary enormously, both from patient to patient and, over time, in one patient.  There are three primary courses the disease may take:

  • A benign course, involving a few early mild attacks followed by almost complete remission, leaving little or no disability (30% of cases)
  • An exacerbating-remitting course with more early attacks with less complete remission resulting in some disability, followed by long periods of stability (40% of cases)
  • A progressive course involving a slow and continuing progression of the disease with no remission (30% of cases).

Diagnosis and Tests

Diagnosis of MS is difficult.  A medical history and clinical examination must show at least two separate lesions that have occurred at more than one time.  Obviously, any other possible causes must be ruled out.  Because of the difficulty of diagnosis, the presence of MS is usually deemed to be either definite, probable, or possible.  There is no one specific diagnostic test that can either confirm or rule out its presence.

A neurological examination can indicate lesions through the presence or absence of various signs and reflexes.  Computerized tomographic (CT) scans will show some lesions.  Magnetic resonance imaging (MRI) usually reveals many more lesions than the CT scan, including some that may be subclinical.  An autopsy will usually show many more lesions than were suggested by either symptoms or signs.  These lesions are probably the result of subclinical attacks of the disease. 

Brain wave testing of responses to various forms of stimulation of the eyes, ears or other parts of the body may demonstrate delays in these responses and indicate lesions that are clinically silent (producing no symptoms) and can sometimes firm up a questionable diagnosis from probable to definite MS.  Testing of the cerebrospinal fluid for protein content, the number and type of white blood cells, and the amount of Ig6, a gamma globulin, can also support a diagnosis.  An old diagnostic technique is to see whether a person becomes worse after a hot bath.

Treatment and Prevention

There is no cure for multiple sclerosis.  Many promising modes of treatment are being developed and tested but most remain experimental.  An enormous amount of research is currently being done on the causes and processes of multiple sclerosis, and understanding of the disease continues to increase.

The Swank Diet
Dr. Roy Swank has provided convincing evidence that a diet low in saturated fats over a long period of time can slow down and in some cases stop the degenerative process in multiple sclerosis.  The Swank diet calls for:

  1. No red meat for the first year of the diet (including the dark meat of turkey and chicken).  Following the first year, 3oz of red meat will be allowed per week
  2. No dairy products containing 1% butterfat or more
  3. No processed foods containing saturated fat
  4. Saturated fat intake below 15gm (3 teaspoons) per day
  5. Unsaturated fat intake at a minimum of 20gm (4 teaspoons) and a maximum of 50gm (10 teaspoons) per day
  6. 1 teaspoon or 4 capsules of cod liver oil each day
The results of Dr. Swank's 34-year study from 1949-1984 are impressive.  Patients diagnosed as minimally disabled showed very little progression of the disease.  Only 5% of the diet group failed to survive the 34 years of the study while a remarkable 80% of those not following the diet failed to survive the same time period.  Moderately and severely disabled patients progressed much better subjectively and objectively than those that did not follow the diet.  The diet has been credited with preventing a worsening of the disease, greatly reducing fatigue, and dramatically reducing the death rate.

Prognosis

Some of those with an exacerbating-remitting course will eventually develop a slow progression involving fewer and less complete remissions with cumulative disabilities.  Very rarely, there is a rapidly progressive course leading to death.  MS itself is almost never the cause of death; death results from accompanying complications or infections.  Generally speaking, the life expectancy of those with MS is at least 75% of normal.

Exacerbations and remissions are difficult to define.  An exacerbation is an acute appearance of new symptoms or worsening of old symptoms which lasts at least 24 hours, while a remission is a total or more often partial clearing of symptoms and signs which lasts more than 24 hours.

Exacerbations – episodes of new disease activity – are not easy to diagnose with certainty.  New symptoms may result from old, not new, areas of disease that were previously silent.  Conversely, recurrence of old symptoms is not a sure indication of lack of exacerbation.  Over time, the disease process may result in the formation of new plaques or the enlargement of existing ones.  Exacerbations can be caused by heat, physical trauma, extreme fatigue, psychological stress, infections, or any other kind of stress.  While all of these factors have been associated with exacerbations, there is little empirical data to support these associations.

There does seem to be a direct correlation between the degree of remission from an exacerbation and its duration.  For example, 85% will usually improve spontaneously from an exacerbation that lasts one week, but only 7% will improve after an exacerbation lasting one to two years.  Over time, a series of exacerbations and remissions may result in a gradual accumulation of irreversible changes and disability.

There are factors that may be predictive of the course of the disease.  An earlier age at onset may mean a more benign course.  If, at onset, symptoms are sensory, the course of the disease may be less severe, while motor symptoms (weakness or poor coordination) at onset may be predictive of greater disability.  Again, as with everything to do with this disease, variation is extreme and the course and progression of the disease is unpredictable.

Signs, symptoms & indicators of Multiple Sclerosis:

Lab Values - Cells

Symptoms - Environment

Minor/severe cold weather muscle spasms is often a sign or symptom of Multiple Sclerosis Minor/severe cold weather muscle spasms

Very cold temperatures, or changes in temperature, can cause MS symptom flare-ups, in particular spasticity.

Poor tolerance of heat may be a sign or symptom of Multiple Sclerosis Poor tolerance of heat

Damaged nerve fibers have a strongly diminished tolerance for heat.  Increases as little as 0.1 degrees centigrade can decrease conduction or cause blockage, which will result in the appearance of symptoms.

Counter-indicators
Counter-indicators
No cold weather muscle spasms may contraindicate Multiple Sclerosis No cold weather muscle spasms

Very cold temperatures, or changes in temperature, can cause MS symptom flare-ups, in particular spasticity.

Symptoms - General

(Severe) fatigue after slight exertion may be a sign or symptom of Multiple Sclerosis (Severe) fatigue after slight exertion

Demyelinated nerve fibers use more energy to conduct impulses and thus fatigue more easily than normal fibers.  MS involves large numbers of nerve fibers in a state of borderline function, which suddenly turn off when the body temperature is elevated only one or two degrees.  The signals suddenly cease to be transmitted, and one has to stop.  Muscles that have been weakened result in a reliance on stronger muscles, which then tire faster.  One recent report indicates that for those with MS the energy cost of walking is two to three times that of a normal person over the same distance.  Such an increased use of energy obviously results in increased fatigue.  The fatigue of MS is hard to describe.

Symptoms - Head - Eyes/Ocular

Symptoms - Head - Mouth/Oral

Rapid decline in speaking ability may be a sign or symptom of Multiple Sclerosis Gradual/rapid decline in speaking ability

Difficulty speaking may result from a variety of neurological disturbances, including Multiple Sclerosis.  Weakness, stiffness, or uncoordinated movement of the muscles controlling the lips, tongue, jaw, soft palate, vocal cords and diaphragm can all cause speech problems.

Symptoms - Mind - Emotional

Symptoms - Muscular

Specific/severe muscle weakness is often a sign or symptom of Multiple Sclerosis Specific/severe muscle weakness

Gait disorders varying from an inability to walk the usual distance to an inability to walk at all are the principal problems of patients with MS.

Symptoms - Nervous

Conditions that suggest Multiple Sclerosis:

Aging

Hearing Loss may suggest Multiple Sclerosis Hearing Loss

Multiple sclerosis that affects auditory nerve pathways in the brain can cause sensorineural hearing loss.

Mental

Musculo-Skeletal

Counter-indicators
Gout / Hyperuricemia strongly contraindicates Multiple Sclerosis Gout / Hyperuricemia

It has been reported that MS (possibly associated with low uric acid) and gout (associated with high uric acid) are mutually exclusive.  A study of 20 million Medicare and Medicaid records found no overlap between MS and gout.

Organ Health

Vertigo often suggests Multiple Sclerosis Vertigo

Vertigo is a fairly common symptom of multiple sclerosis, occurring in about 20% of sufferers at some point.  It is an acute, uncomfortable sensation, making those who are already a little unsteady feel even more nervous about moving around.  It is not a permanent symptom, but may indicate a new lesion or inflammation.

This vertigo can be caused by lesions in the cerebellum, or it can be a result of damage to the nerves that control the vestibular functions of the ear in the brain stem.  Vertigo is, however, not always a direct result of the MS disease process.

Symptoms - Immune System

Uro-Genital

Risk factors for Multiple Sclerosis:

Addictions

Cigarette Smoke Damage may increase risk of Multiple Sclerosis Cigarette Smoke Damage

A study at the University of Bergen in Norway, reported October 28th, 2003 in the journal Neurology, found that smoking can more than double a person's chances of developing multiple sclerosis.  The risk was higher even if people had given up cigarettes.  The authors, Dr. Trond Riise and colleagues, examined 22,312 people aged between 40 and 47.  Of those, 87 had MS.  The smokers were 1.81 times more likely to get MS than the non-smokers and men had a higher (2.75 times more likely) risk than women (1.61) who had smoked.

Autoimmune

Circulation

Environment / Toxicity

Mercury Toxicity (Amalgam Illness) may increase risk of Multiple Sclerosis Mercury Toxicity (Amalgam Illness)

A 1987 study showed that the levels of mercury in the spinal fluid of MS patients was 8 times higher than normal.  [Silberod, R: A comparison of mental health of multiple sclerosis patients with silver/mercury dental fillings; Psychological Reports 70: pp.1139-51, 1992].  Mercury has long been linked to autoimmune diseases such as MS because of its affinity to attach to collagen tissue, which is the most common protein in the body.  Polluted by mercury infiltration, the collagen is seen by the immune system as 'not self.'

Lab Values

Uric Acid Levels Low may increase risk of Multiple Sclerosis Uric Acid Levels Low

It has been proposed – and research is supporting the idea – that low uric acid levels are associated with increased frequency and longer bouts of multiple sclerosis.  Uric acid works by inactivating peroxynitrite, a toxic compound that may cause damage to the central nervous system in MS patients.  Researchers report that they found lower levels of uric acid in the blood of MS patients than of people without the disease.  It appears that high serum uric acid levels protect against the development of MS.  These results raise the possibility that the natural biologic product, uric acid, or a more soluble peroxynitrite scavenger that penetrates the blood brain-barrier more readily might have clinical utility in the treatment of MS.  [Proceedings of the National Academy of Sciences 1998;95: pp.675-680]

Nutrients

EFA Type 3 Requirement may increase risk of Multiple Sclerosis EFA (Essential Fatty Acid) Type 3 Requirement

Polyunsaturated omega-3 fatty acid deficiency may contribute to depressive symptoms in alcoholism, multiple sclerosis and postpartum depression.

It is interesting to note that the incidence of MS is quite low in Japan, where consumption of marine foods, seeds, and fruit oil is quite high.  These foods contain abundant polyunsaturated fatty acids, including the omega-3 oils (alpha-linolenic, eicosapentaenoic, and docosahexanoic acids).  Deficiencies of the omega-3 oils are thought to interfere with lipid elongation and permanently impair formation of normal myelin.

Uro-Genital

Multiple Sclerosis suggests the following may be present:

Autoimmune

Hormones

Multiple Sclerosis may suggest Progesterone Low or Estrogen Dominance Progesterone Low or Estrogen Dominance

Progesterone has been shown in animal studies to promote the formation of new myelin sheaths [Human Reproduction 2000 Jun;15 Suppl 1: pp.1-13, J Steroid Biochem Mol Biol 1999 Apr-Jun;69 pp.97-107, Mult Scler 1997 Apr;3 pp.105-12]

Physicians have known for years that pregnancy can suppress some forms of immune response, such as allergies.  In the early and mid-1980s, several doctors observed that MS patients had fewer symptoms during pregnancy and post-partum recovery.  This may be due to the high progesterone level in the blood of a pregnant woman.  Progesterone tends to be anti-inflammatory.  Progesterone therapy may therefore be useful for MS especially as a medical report noted the association between enlarged adrenal glands and MS.  Progesterone, being a steroid, often helps the adrenals deal with inflammation.

Other studies have indicated that symptoms are worse during periods when the progesterone to estrogen ratio is low.

Lab Values

Multiple Sclerosis often suggests Uric Acid Levels Low Uric Acid Levels Low

It has been proposed – and research is supporting the idea – that low uric acid levels are associated with increased frequency and longer bouts of multiple sclerosis.  Uric acid works by inactivating peroxynitrite, a toxic compound that may cause damage to the central nervous system in MS patients.  Researchers report that they found lower levels of uric acid in the blood of MS patients than of people without the disease.  It appears that high serum uric acid levels protect against the development of MS.  These results raise the possibility that the natural biologic product, uric acid, or a more soluble peroxynitrite scavenger that penetrates the blood brain-barrier more readily might have clinical utility in the treatment of MS.  [Proceedings of the National Academy of Sciences 1998;95: pp.675-680]

Nutrients

Multiple Sclerosis often suggests EFA Type 3 Requirement EFA (Essential Fatty Acid) Type 3 Requirement

Polyunsaturated omega-3 fatty acid deficiency may contribute to depressive symptoms in alcoholism, multiple sclerosis and postpartum depression.

It is interesting to note that the incidence of MS is quite low in Japan, where consumption of marine foods, seeds, and fruit oil is quite high.  These foods contain abundant polyunsaturated fatty acids, including the omega-3 oils (alpha-linolenic, eicosapentaenoic, and docosahexanoic acids).  Deficiencies of the omega-3 oils are thought to interfere with lipid elongation and permanently impair formation of normal myelin.

Multiple Sclerosis can lead to:

Musculo-Skeletal

Multiple Sclerosis could instead be:

Infections

Lyme Disease is very occasionally misdiagnosed as Multiple Sclerosis Lyme Disease

Lyme Disease has been called "The New Great Imitator", a replacement for that old "great imitator" neurosyphilis.  The two diseases share so many symptoms that Lyme disease should be ruled out if multiple sclerosis diagnosis is in question.

Recommendations for Multiple Sclerosis:

Animal-based

Thymic Factors may help with Multiple Sclerosis Thymic Factors

Through his clinical experiences with thymic supplementation, Dr. Burgstiner said he observed 10 cases of multiple sclerosis go into remission.

Botanical

Ginkgo Biloba often helps with Multiple Sclerosis Ginkgo Biloba

Three months of treatment with a Ginkgo biloba product (240mg per day) maintained attention, memory and functioning – without adverse effects – in a double-blind, placebo-controlled study of 23 patients with mild multiple sclerosis.  Deterioration of function was observed in patients who had received a placebo.  [American Academy of Neurology 54th Annual Meeting, April 13-20, 2002, Denver, Colorado, USA; P06.081]

Diet

Monounsaturated Oils often helps with Multiple Sclerosis Monounsaturated Oils

A minimum of 20gm (4 teaspoons) and a maximum of 50gm (10 teaspoons) per day is recommended as part of the Swank Diet for Multiple Sclerosis sufferers.  Persons with MS should use mainly olive oil (monosaturated fat) in conjunction with fish oils to provide most of their fat intake.

Plant-Based Nutrition often helps with Multiple Sclerosis Plant-Based Nutrition

A vegan/vegetarian diet satisfies several of the requirements set out in the Swank Diet for Multiple Sclerosis.

Animal/Saturated Fats Avoidance often helps with Multiple Sclerosis Animal/Saturated Fats Avoidance

This is part of the Swank Diet for Multiple Sclerosis sufferers.

Fried Foods Avoidance often helps with Multiple Sclerosis Fried Foods Avoidance

The Swank diet includes strict avoidance of fried food and trans-fatty acids.

Dairy Products Avoidance often helps with Multiple Sclerosis Dairy Products Avoidance

Avoid dairy products containing 1% butterfat or more.  This is part of the Swank Diet for Multiple Sclerosis sufferers.

Hydrogenated Fats Avoidance often helps with Multiple Sclerosis Hydrogenated Fats Avoidance

The Swank diet includes strict avoidance of fried food and trans-fatty acids.

Increased Fish Consumption often helps with Multiple Sclerosis Increased Fish Consumption

The Swank diet includes eating fish at least 3 times per week.  Alternately, fish oils could be substituted at 1500mg three or more times per week.

Not recommended
Chocolate is sometimes not recommended for Multiple Sclerosis Chocolate

Epidemiology studies have documented a correlation between high cocoa consumption and high MS incidence.  When cocoa is introduced to an area, MS incidence rises sharply.  Cases are reported in which chocolate ingestion by MS patients was followed by exacerbations [Maas AG, Hogenhuis LAH.  Multiple sclerosis and possible relationship to cocoa: A hypothesis.  Ann Allergy 59: pp.76- 9, 1987]

Drug

Conventional Drug Use is highly recommended for Multiple Sclerosis Conventional Drug Use

A form of bacteria seems to be the organic cause of multiple sclerosis, claims a Dr. Hoekstra, MD.  Its tentative name – not yet widely accepted by other microbiologists – is Borrelia mylophora, so named because its characteristics seem to resemble those of Borrelia burgdorferi, the bacteria believed responsible for Lyme disease.  In cases of multiple sclerosis, the myelin sheath covering the nerves gets eaten away by the immune system, explains Dr. Hoekstra.  "That is exactly like the hunters' torches setting fire to the forest.  Most of the destruction of the myelin sheath takes place from actions of the white blood cells and their antibodies.  But their primary target is not the myelin sheath at all.  It's the Borrelia mylophora bacteria, running around in the nervous system.  B.  mylophora has an extremely high affinity for the myelin sheath.  It loves it."

The successful use of doxycycline against B.  mylophora was first verified by a physician in South Dakota who reasoned that the symptoms of MS (which he had) were suggestively similar to those of Lyme disease, which responds fairly well to doxycycline.  After dosing himself for three months with the antibiotic, he was symptom free.  However, the long-term use of antibiotics has many drawbacks, cautions Dr. Hoekstra.  It seriously damages the ecology of intestinal microflora and can lead to a condition of microbial imbalance called dysbiosis.  This in turn can be the foundation for numerous diseases.  It can also facilitate the growth of more cell wall deficient forms.  To counteract this, probiotic replacement is required.

Hormone

Histamine Therapy often helps with Multiple Sclerosis Histamine Therapy

Dr. George Gillson, M.D., Ph.D., reports that after six weeks of treatment with histamine in 19 individuals with multiple sclerosis

  • 11 noted dramatic improvement
  • 3 reported one or more significant improvements in symptoms, including reduced numbness, better motor control, improved speech, much better sleeping, and more energy
  • 1 had no change
  • 4 had no change due to poor absorption of the histamine, poor patch adhesion, or an interfering drug.
The nurse responsible for the revival of the use of histamine, Elaine DeLack, MS, RN, has collected verbal reports from over 200 individuals diagnosed with multiple sclerosis who have used histamine: 72% report at least one significant improvement in symptoms, and some many more.

ACTH (Adrenocorticotropic Hormone) often helps with Multiple Sclerosis ACTH (Adrenocorticotropic Hormone)

One hormone which has been shown to shorten the duration and intensity of acute exacerbations is adrenocorticotropic hormone (ACTH), a pituitary gland substance that stimulates the adrenal glands to produce additional cortisone, which acts to reduce the inflammation in the brain or spinal cord.  ACTH does not affect the underlying disease processes but may diminish the frequency and severity of exacerbations and even slow the progression of the disease.

Pregnenolone may help with Multiple Sclerosis Pregnenolone

Animal studies indicate that pregnenolone may aid in repairing the degeneration of the myelin sheath, the cause of Multiple Sclerosis.  Further studies are required to determine if there is any benefit for humans with MS.

Lab Tests/Rule-Outs

Test for B12 Levels is highly recommended for Multiple Sclerosis Test for B12 Levels

The first step when you receive a diagnosis of multiple sclerosis is to determine if you really have it.  A vitamin B12 deficiency has very similar symptoms and is frequently misdiagnosed as MS; the type of anemia resulting from B12 deficiency is called pernicious anemia.  [Hosp Pract (Off Ed) 1995 Jul 15;30(7): pp.47-52; discussion 52, 54]

Additionally, researchers found in 45 MS patients that vitamin B12 levels were significantly lower in those who experienced the onset of first neurological symptoms prior to age 18 years (10 patients) compared to patients in whom the disease first manifested after age 18 (35 patients).  In contrast, serum folate levels were unrelated to age of onset of the disease.  As vitamin B12 levels were statistically unrelated to chronicity of illness, these findings suggest a specific association between the timing of onset of first neurological symptoms of MS and vitamin B12 metabolism.  In addition, since vitamin B12 is required for the formation of myelin and for immune mechanisms, a deficiency in MS is of critical pathogenetic significance.  [PMID: 8407160, UI: 94011702]

Test Serum Uric Acid Levels is highly recommended for Multiple Sclerosis Test Serum Uric Acid Levels

Reports from researchers suggest that low uric acid levels are associated with increased frequency and longer bouts of multiple sclerosis.  Uric acid levels should be monitored and, if low, raised by supplemental molybdenum and reducing any copper toxicity.

Mineral

Calcium-2AEP often helps with Multiple Sclerosis Calcium-2AEP

Calcium EAP protects the myelin sheath from damage by an autoimmune response.  Dr. Nieper has found an EAP deficiency state in people with immune dysfunctional diseases, and says that all cell membranes in such people are defective.  He claims this defect can be blocked with supplemental EAP.

Dr. Nieper believes that MS is initiated by a viral attack on the nervous system, followed by an error in programming the immune system to defend it.  The immune system ends up attacking the nerves, especially the myelin sheath.  Normally, certain steroids eliminate this bad programming but certain pollutants such as Chlorine, Fluoride, some heavy metals and especially Aluminum, interfere with the process.

Nutrient

Essential Fatty Acids often helps with Multiple Sclerosis Essential Fatty Acids

The Swank diet includes a blend of 40-50gm per day of essential fatty acids as well as at least 1 teaspoon of cod liver oil per day.

Vitamins

Vitamin B1 (Thiamine) is highly recommended for Multiple Sclerosis Vitamin B1 (Thiamine)

Dr. Fred Klenner, MD pioneered the use of injectable thiamine (vitamin B1) and injectable liver extract for the treatment of multiple sclerosis.  His experience and that of others is that early treatment is important in producing symptomatic relief and a state of well-being.

KEY

Weak or unproven link: may be a sign or symptom of; may suggest; may increase risk of; is very occasionally misdiagnosed as
Weak or unproven link:
may be a sign or symptom of; may suggest; may increase risk of; is very occasionally misdiagnosed as
Strong or generally accepted link: is often a sign or symptom of; often suggests; often leads to
Strong or generally accepted link:
is often a sign or symptom of; often suggests; often leads to
Definite or direct link: strongly suggests
Definite or direct link:
strongly suggests
Weakly counter-indicative: may contraindicate
Weakly counter-indicative:
may contraindicate
Definitely or absolutely counter-indicates: strongly contraindicates
Definitely or absolutely counter-indicates:
strongly contraindicates
May be useful: may help with
May be useful:
may help with
Moderately useful: often helps with
Moderately useful:
often helps with
Very useful: is highly recommended for
Very useful:
is highly recommended for
Caution: is sometimes not recommended for
Caution:
is sometimes not recommended for