American Parkinson Disease Association, Washington Chapter

By Cynthia A. Holmes, PhD, Coordinator, APDA Information & Referral Center, Tucson, AZ

As we approach the year 2000 Parkinson's disease (PD) remains a condition we can neither prevent nor cure. While researchers work to change this fact, most doctors rely on medications or surgery to relieve patient symptoms such as tremor, rigidity, slowness and problems with balance and posture. These treatments may be wonderfully effective for some patients but others experience only partial relief or are bothered by side effects. Many find that these treatments seem less effective as the disease progresses.

For these and other reasons, a growing number of individuals, faced with a decade or more of living with PD, experiment with alternative therapies on their own or visit alternative practitioners. These alternative practices include acupuncture, the use of herbs and nutritional supplements, chiropractic manipulation and other types of body work, and mind-body techniques such as meditation or guided imagery. A surprising number of patients use these approaches without informing their neurologists, perhaps fearing that their doctors will disapprove. While this fear is sometimes warranted, the integrative approach is gaining wide acceptance, even among specialty physicians.

Integrative medicine definition

Integrative medicine selects from or combines the best of conventional and alternative medicine. But it is more than an expansion of the western medical arsenal. According to Dr. Andrew Weil, Director of The Integrative Medicine Program at the University of Arizona, "The integrative approach is based on physician/patient partnership within which conventional and alternative modalities are used to stimulate the body's natural healing potential. It neither rejects conventional medicine nor uncritically accepts alternative practices." Dr. Tracy Gaudet, the program's Medical Director, explains that physicians who use the integrative approach work from a model of health rather than disease, take the time to listen, attend to nutritional and lifestyle influences on health and illness, offer treatments in addition to drugs and surgery, and understand the potential of the human organism for self-repair and healing.

Public and professional interest

If you have visited an alternative practitioner, you are not alone. A 1997 survey published in the Journal of the American Medical Association showed that there were more than 600 million visits to alternative practitioners that year and that the amount spent on these practices was approximately $27 billion dollars.

Professional interest has been stimulated by consumer demand. Seventy-five medical schools now include courses on integrative medicine, health insurers have started to expand benefits to cover certain alternative medicine services, and the American Medical Association has devoted an entire issue of each of its journals to complementary and alternative medicine. In the November 1998 special issue of Archives of Neurology, Editor Richard Rosenberg, MD, comments that "Neurological disease are difficult to treat and thereby offer room for speculative approaches and ideas."

Selected alternative therapies and their applicability to Parkinson's disease

The list of alternative therapies is long. Some approaches have plausible biological mechanisms and others appear to work much as a placebo would, creating a beneficial effect because of the belief on the part of the patient and the provider that it will help. As an aside, the placebo effect, once thought of only as an obstacle to researchers trying to determine the effectiveness of new treatments, is now regarded by integrative medicine specialists as something to be cultivated for its ability to stimulate the body's natural healing response. Table 1 lists alternative practices for which one or more clinical trials have been conducted to determine their effectiveness for PD. The number of clinical trials for each practice is shown in parentheses. Brief descriptions of these practices appear below. The reader is referred to Jonas and Levin for more complete information about these practices or for information about practices not listed here.

Aromatherapy. Uses the aromatic oils of plants to improve and maintain well-being. More than three hundred different oils are produced from flowers, leaves, stems and roots. The action of aromatherapy depends on the link between smell and memories. Massage and penetration of the oils into the body may also have a direct effect.

Ayurveda. Sanskrit for "life knowledge." One of the oldest known systems of healing. Approaches health as the balance of body, mind, emotion and spirit. Treatments include yoga, meditation, purification regimens, dietary changes and herbal remedies.

Biofeedback. The use of instrumentation to monitor, amplify, and feed back physiological information, so that a client can learn to change or regulate the process being monitored.

Electric stimulation. Application of mild electric shocks to the skin. Used by chiropractors, massage therapists and other practitioners of "body work", for the relief of pain and other symptoms.

Massage therapy. A therapeutic method of manually rubbing, stroking, tapping and kneading the body (either a particular area or the whole body) for the purpose of treating physical and emotional disorders, increasing blood flow, reducing pain, and promoting relaxation, muscle tension release, and general health and well-being.

Naturopathy. Emphasizes the body's ability to heal itself. Therapies include the use of natural foods and medicines that support self-healing. Favors interventions that are non-invasive and have a low incidence of side-effects, such as massage and hydrotherapy. Advises against drugs and surgery. Encourages proper exercise, fresh air, and the creation of a healthful environment.

Orthomolecular/Megavitamin. The adjustment of concentrations of molecules (e.g., vitamins, minerals, amino acids, hormones, and metabolic intermediates that are normally present in the body for the prevention and treatment of disease.

Phytomedicine. Also called herbal or botanical medicine, the term phytomedicine describes the therapeutic ingestion or topical application of plants. Herbal medicine dates back at least 5000 years and has been used by all races, religions, and cultures throughout the world.

Relaxation techniques. Basic techniques include progressive muscle and relaxation and diaphragmatic breathing. More advanced techniques include self-hypnosis, guided imagery, and meditation. Once these techniques are mastered they are readily available to use when stress exacerbates symptoms.

Evidence for safety and efficacy

Alternative therapies that have the potential to benefit people with Parkinson's must also be evaluated for their potential to do harm. Natural does not necessarily mean safe. And remember one potential harm is harm to your bank account if you pay for therapies that don't work. With these points in mind, let us consider what evidence is available for safety and effectiveness. Methods of investigation include qualitative research (case studies and patient interviews), laboratory and basic science approaches, observational studies (monitoring outcomes on a sample of patients who receive treatment and pre- and post-evaluations), randomized controlled trials (the gold standard for research, and the method required to determine the safety and efficacy of new prescription medications), and health services research (examining outcomes and other factors in groups of people already using a particular approach).

And what of your own subjective assessment? Do you need a randomized controlled trial to tell you that massage makes you feel better? Do you have to wait for proof of safety before you give it a try? Common sense suggests that there are some approaches you may be willing to try without such proof and others for which you will insist that there be evidence. Reliable evidence is forthcoming as more and more alternative approaches are evaluated in carefully designed studies.

Detailed discussion of specific practices must be left for future articles. However, one example will serve to illustrate how research can help us take an "evidence-based" approach to the use of alternative therapies. The Indian system of medicine (Ayurveda) uses the herb "atmagupta", (the seed of mucuna pruriens) to treat PD. This herb has been used in humans in India for centuries, and no serious adverse reactions have been reported (evidence for safety). In 1937 it was discovered that mucuna beans contain natural levodopa (a plausible biological mechanism). An uncontrolled trial conducted in 1978 suggested that a powder made from the whole beans of mucana relieved symptoms and decreased the incidence of side-effects when compared to synthetic levodopa (evidence for effectiveness). A 12-week open trial of 60 Parkinson's patients conducted in 1995, using a formulation made from mucuna endocarp, supported the earlier finds (further evidence for effectiveness). Whether you feel these finds constitute adequate evidence for safety and efficacy of mucuna depends on factors unique to your training and experience. The take-home message is that, if you are a patient who decides to purchase mucuna from a health food store, advise your neurologist and ask for his or her opinion. If you are a Parkinson's doctor, be sure to ask our patients if they are taking any herbs or supplements or if they are using other alternative practices (many surely are). Optimal treatment is only possible when all relevant factors are revealed and discussed.

Conclusion

Integrative Medicine selects from or combines the best of conventional and alternative medicine. While many alternative therapies have been around for centuries, the current popularity of alternative medicine is relatively new. Patients must recognize that there is a powerful consumer movement favoring the use of alternative medicine, but only some scientific research to document safety and efficacy. At present, most neurologists cannot offer much guidance about alternative therapies and Parkinson's. Nevertheless, patients should consult with their doctors before beginning any new therapy. You and your doctor can learn about these practices together.

Reprinted with permission from the American Parkinson Disease Association, Inc. Newsletter, Spring 2000 News