33
CHAPTER
Alternative Therapies
William L. Bell
What is considered mainstream versus alternative therapies in medicine is very dependent on time and geography. The late nineteenth-century classic texts by Gowers and others cite various salts of bromide as the accepted treatment for human epilepsy, with a variety of medications including Cannabis indicus (tincture) mentioned as alternative treatments (1). Today alternative treatments are often called complementary as they complement rather than replace modern medical therapies. Complementary and alternative (CAM) therapy may seem new, but many of these treatments are traditional remedies in other cultures going back several thousand years. These therapies are the accepted primary healthcare by those whose access to modern medicine is limited by a host of geographic, economic, cultural, or religious factors. A 2002 survey of U.S. adults found that when megavitamin therapy and prayer were included, 62% had used at least one CAM therapy in the past 12 months. When megavitamin therapy and prayer were excluded, the number fell to 35%, but this still represents more than a third of Americans (2). A similar percentage of surveyed patients in epilepsy centers use CAM for the treatment of epilepsy and other ailments (3,4). Many of these patients did not inform their physicians that they were using CAM, an important finding considering that many herbal remedies have significant interactions with antiepileptic drugs (AEDs) (3).
As we consider various categories of CAM, it is important to note that few randomized controlled trials exist and the ones that exist are not double-blind studies. For the controlled trials that have been accomplished, the numbers in each treatment and control group were small, making the studies difficult to interpret.
MIND–BODY THERAPIES
Patients frequently report an increase in seizures during times of stress, sleep deprivation, and fatigue. In general, idiopathic generalized seizures are prone to be increased by sleep deprivation and partial seizures by stress (5). These factors are part of life and many neurologists have had the experience of admitting patients to epilepsy monitoring units with well-documented frequent seizures, but after admission these patients have few events even with medication reduction. This may be a clue as to how much the stresses of everyday life affect seizure frequency. Therefore, it is natural to look at means to mitigate stress and other factors in patients.
Prayer
Although prayer is not always considered CAM, in a survey of epilepsy patients in Arizona, prayer and stress management techniques were the most common methods used, followed by herbal supplements (4). Similar findings were found in a survey of 149 epilepsy patients in Kansas with prayer/spirituality (41%) most common followed by “mega” vitamins (22%), chiropractic care (21%) and stress management (14%). Thirty-six patients used prayer/spirituality specifically for their epilepsy and 33 (89%) reported benefit (3). However, there are no controlled studies for prayer and epilepsy and this is a difficult arena to design a study. What constitutes healing prayer varies significantly between faiths in the Western traditions.
Yoga and Meditation
In a review of 82 studies that attempted to measure the efficacy of meditative techniques, the studies with the most dramatic results were those using Sahaja yoga for the treatment of epilepsy. One study randomized patients into three groups: 6 months of Sahaja yoga, 6 months of exercises mimicking Sahaja yoga, and 6 months of neither. In the first group, there was an 86% reduction in seizures with no improvement in the other two groups (6). These results have not been replicated. There are many varieties of yoga, and Sahaja yoga emphasizes the dhyana or meditative components. Hatha yoga is a more eclectic type of yoga that includes a variety of yoga components, but there is more of an emphasis on physical postures and is one of the most common types of yoga practiced in the United States. A study comparing Hatha yoga and routine exercise in epilepsy patients showed improvement in parasympathetic parameters and a reduction in seizure frequency in the yoga group but not the exercise group. Adverse effects are uncommon, but yoga participants should be in good physical condition and aware of their skill levels to avoid overstretching, strains, and fractures. Inverted poses can increase intraocular pressure, worsening glaucoma (7). Finally, yoga may not appeal to patients who are put off by yoga’s connections to Hindu and Buddhist spiritual traditions.
Transcendental meditation (TM), although derived from ancient yogic teachings, deserves separate mention as the most popular form of New Age meditation. Trademarked by its founder Maharishi Mahesh Yogi, it is officially nonreligious, although one of its goals is to attain “God Consciousness.” Along with postures and breathing exercises, the participants enter into a trance by allowing an assigned secret sound or mantra to overcome the mediator’s thoughts. It differs from other techniques in that it is highly standardized and teachers must be certified. There have been anecdotal reports of seizures provoked by TM and others report benefit with a reduction of seizures. However, there have been no controlled clinical trials (8).
Mindfulness meditation and mindfulness-based stress reduction, which pair meditation with yoga, are popular mind–body therapies developed by Jon Kabat-Zinn, but there are no controlled studies for the treatment of epilepsy (6). Christian meditation has a history that goes back centuries and continues to thrive in both Protestant and Catholic circles. Also known as centering prayer, it has been used in the management of depression, but not for neurologic disorders.
Relaxation Therapy
Progressive muscle relaxation was developed by Edmund Jacobsen in the 1920s. The patient tenses and releases sequentially muscle groups one at a time. The tension phase should be 10 to 20 seconds and the relaxation phase should last 20 to 30 seconds. This is practiced for 20 minutes twice a day in a comfortable and quiet environment. In one small controlled study, 13 patients with progressive relaxation had a 29% reduction in seizures compared to the control group of 11 patients with quiet sitting who had a 3% reduction. With only a limited number of individuals studied, no definite conclusions can be made (9).
Self-Control and Counter-Measures
Many patients identify common situations in which they tend to have seizures. Patients surveyed by Dahl found that seizures followed drowsiness (84%), physical activity (83%), negative stress (78%), muscle tension (71%), demanding situations (67%), and panic (64%). Sixty-nine percent of patients thought that they could reliably trigger a seizure by such means as hyperventilation, imitation of seizure movement or thoughts, and by intermittent periods of high-energy physical activity followed by sudden rest (10).
Application of countermeasures to prevent or limit seizures goes back to the first and second centuries. A ligature was placed around a limb with a sensory aura to prevent the spread of a seizure. It was thought the ligature could keep a seizure-triggering humoral substance from spreading like venom. Such countermeasures continued into late nineteenth century with Gowers recommending a variety of countermeasures: ligature proximal to convulsion, forcible prevention of spasm, cutaneous stimulation, activity such as walking around room, strong olfactory and gustatory stimulation (1). In Dahl’s study, patients with simple partial seizures developed countermeasures spontaneously including restraint of motor movement (74%), stimulation of the area of sensation (77%), stimulation using auditory (85%), olfactory (32%), or visual stimuli (22%). Also sometimes effective were applied relaxation in 78% and/or using positive statements in 89%. For those with complex partial seizures, they spontaneously used restraint of motor automatism in 78% and general arousal in 57% using a variety of sensory stimuli. Many of the author’s patients report that a family member can limit the extent of the seizure through verbalization or touch. Discovery of countermeasures can be facilitated by the ABC method according to Fenwick. “A” is for antecedent experiences that occur before seizure onset. If there are some common experiences before a seizure, perhaps a countermeasure could be designed to address those experiences. “B” is for behavior. A patient who felt that a simple partial seizure would engulf him, he could snap a rubber band on his wrist resulting in pain so as to maintain control of the seizure. “C” is for consequence (10). For example, could a patient be rewarded or punished in any way for having a seizure? Whether this knowledge helps control seizures or not may be debatable, but learning of psychosocial consequences is useful for managing the patient. The author had a patient who was embarrassed at school by excessive attention paid to her seizures by teachers and school staff. This led to an aversion to going to school and eventually homebound instruction even though the seizures themselves were not frequent or disruptive. Countermeasures have been more systematically studied as part of comprehensive neurobehavioral programs.
Reflex Epilepsies
In the official International League Against Epilepsy (ILAE) classification of epilepsies, reflex epilepsies are placed in a special category regardless of whether focal or generalized and characterized by specific types of provocation. Once the patient can identify seizure precipitants, they may be able to avoid those stimuli. The precipitants may be more likely to trigger a seizure when the patient suffers stress or lack of sleep. Many different stimuli have been described, including listening to music, eating, bathing, calculating, thinking, and decision making. Photosensitive patients report more seizures evoked by flickering lights or videogames, following sleep loss and some authors have reported increased EEG photosensitivity after sleep deprivation. Photosensitive epilepsy is the most common type of reflex epilepsy. Preventive measures include avoiding videogames, certain types of video and computer screens, and environments with flashing lights. Wearing blue-colored lens (Zeiss Clarlet F133 Z1) and covering one eye may help prevent seizures with the approach of potentially provocative visual circumstances (5). The author had a patient who tinted his car windows successfully limiting the effect of sunlight flashing through trees. Unfortunately, he ran afoul of his jurisdiction’s window tinting law.
Biofeedback
Biofeedback is a treatment in which physiologic parameters normally hidden from conscious awareness are measured and displayed back to the patient such that the parameter comes under conscious control. Using galvanic skin response biofeedback, there was a modest reduction of seizures in a single-blind, randomized controlled study of 18 patients with 10 biofeedback active and 8 sham controls. Six of the 10 patients showed a 50% or greater reduction in seizures. EEG biofeedback also known as neurofeedback has been used for many years in experimental protocols for the treatment of epilepsy, but studies have been small and not properly controlled. The desired parameter usually is a sensorimotor rhythm typically ranging from 12 to 14 Hz. When the rhythm is present, a reinforcing visual or auditory stimulus is given to the patient. In a meta-analysis of 243 patients from 24 studies, about 82% of patients showed a 50% reduction or greater reduction in seizures. For the different studies the training sessions ranged from 60 to 90 minutes and occurred one to three times a week over 6 to 24 weeks. This requires extensive commitment and may not be practical for many patients (9,11).
Comprehensive Neurobehavioral Programs
There are programs that use a variety of techniques to reduce seizures. Some of these techniques have already been discussed. The Andrews/Reiter (A/R) program starts with obtaining a history of seizure onsets, emotions, and circumstances similar to Fenwick’s ABC method. Patients are also taught techniques to lower internal stress by including progressive relaxation and deep breathing exercises to use at seizure onset. Biofeedback using EMG and EEG is also used to reduce seizures. Finally, patients are given cognitive and behavioral counseling and asked to set life goals (12).
Acceptance and commitment therapy (ACT) is a structured program that is an extension of cognitive behavior therapy, but with links to relational frame theory. The first step for patients is acceptance of aspects about their epilepsy that they cannot change. The goal of the therapy is to create a psychological flexibility and to broaden the patient behavioral repertoire to be able to accomplish chosen values and life goals. Another meaning of ACT is: accept, choose and take action. Patients learn to distinguish themselves from life experiences including their seizures. ACT protocol consists of individual and group sessions. In one randomized controlled study ACT was combined with seizure control countermeasures that were individualized to each patient to serve as the active arm (14 patients). The control group (13 patients) received supportive therapy where therapists created an empathetic and accepting environment where patients could reflect on their lives and problems. Both study conditions included both individual and group sessions. There was a significant reduction in seizure frequency and duration with improved quality of life in the ACT group when compared to the supportive therapy group (9).
MANIPULATIVE AND BODY-BASED THERAPY
Chiropractic is one of many body-based therapies and medical systems. Since its beginnings in the Midwest in the United States in the late nineteenth century, chiropractic has an important, albeit contentious role as a health profession. As of 2000, there were 65,000 chiropractors in the United States and 90,000 worldwide. Ninety percent of patients seek help from a chiropractor for neuromusculoskeletal complaints, mainly back pain, neck pain, and headaches (13). With the prevalent use of chiropractic, it is not surprising that a significant percentage of patients with epilepsy have used chiropractic. In the previously mentioned Arizona survey, 44% of epilepsy patients had used chiropractic, with 38 (10%) using it specifically for seizure control and 16 patients claiming benefit (4). There have been anecdotal reports of epilepsy benefiting from chiropractic care, but no controlled trials. Other manual therapies classified under energy medicine have been used in epilepsy.
ENERGY MEDICINE AND TRADITIONAL ASIAN MEDICINE
Traditional Chinese Medicine
Yin and yang are fundamental concepts in Chinese philosophy and in traditional Chinese medicine (TCM). According to these concepts, within every natural object there are two interacting energy-modes, the yin and the yang. Yang is active, warm, dry, bright, and procreative. Yin is passive, cold, wet, dark, and mysterious and fertile. Yin and yang express two opposing but complementary phenomena that are in dynamic equilibrium. In the human body, when there is an alteration in this equilibrium disease occurs. Also the human body is composed of five phases or elements: wood, fire, earth, metal, and water. Another important concept is qi sometimes translated as energy. Qi is what flows and nourishes; it is closely linked with blood. The therapeutics of TCM mobilize and regulate the movement of qi in the body. One method is acupuncture. Important to this method is the idea of channels and points. There are 12 primary and 2 extraordinary channels and qi is understood to flow through these channels. Along the pathway of the channels are specific points and needles are placed in these points as much as an inch below the skin. Based on the concept that all disease involves the disruption of the flow of qi theoretically, any disease can benefit from acupuncture and related treatments including a proper diet (Table 33.1). The aim of the acupuncturist is to obtain qi at the site of the needle insertion. The qi is felt either objectively or subjectively (13). Despite anecdotal case reports and some interesting animal studies purported to show a mechanism, studies have not shown much benefit. In a Cochran review of acupuncture treatment comparing acupuncture to phenytoin and in another study comparing acupuncture to valproate, there were no consistent differences between the groups. In the only trial where a sham control was used, 29 patients randomized to acupuncture or sham acupuncture, there was a modest reduction in seizures in both groups, but the reduction was not statistically significant (14).
