9 Allen C. Bowling Colorado Neurological Institute, Englewood, CO, USA Clinicians who care for those with multiple sclerosis (MS) may find themselves in awkward situations related to alternative medicine. Many MS patients may ask questions about alternative therapies or provide lists of supplements that they are taking, yet clinicians with conventional medical training may feel that they lack the knowledge or experience to address these issues. However, there is a significant amount of evidence-based information about the safety and efficacy of these alternative therapies, and clinicians with conventional training may actually be in a position to improve the quality of MS care by providing objective information and guidance about these therapies. A variety of terms and definitions are used in the area of alternative medicine. In fact, the term alternative medicine is often used incorrectly. A more general, and often more appropriate, term is unconventional medicine, which refers to forms of medicine that are not widely taught in medical schools or generally available in hospitals. Complementary and alternative refer to the ways in which these unconventional therapies are practiced. Complementary indicates that these therapies are used in conjunction with conventional medicine, while alternative indicates that they are used instead of conventional medicine. Complementary and alternative medicine, often indicated by the acronym CAM, refers to both approaches. The combined use of conventional and unconventional medicine is known as integrative medicine. The National Institutes of Health (NIH) has developed a classification scheme for CAM therapies. In this scheme, there are several major categories of CAM therapies (Table 9.1). One specific therapy may fit into more than a single category. For example, acupuncture could be categorized as an alternative medical system and also an energy therapy. Table 9.1 NIH Classification of CAM Therapies with Representative Examples Over the past two decades, there have been remarkable breakthroughs in the field of MS. Significant advances have been made in the diagnosis, treatment, and pathologic understanding of the disease. There are now many effective disease-modifying as well as symptomatic therapies. Despite these developments, however, conventional MS therapies have limitations. Both symptomatic and disease-modifying treatments may cause side effects or may be partially effective or ineffective in some patients. Furthermore, there may be limited treatment options for some forms of MS, such as progressive disease, and for some MS symptoms, such as weakness, tremor, and incoordination. The limitations of conventional MS therapy, as well as other factors, may lead many MS patients to become interested in, and use, CAM. Multiple studies indicate that one-half to three-fourths of those with MS in the USA and other Western countries use some form of CAM. Among MS patients, the vast majority who use unconventional medicine do so in a complementary manner. In other words, they use unconventional medicine in combination with conventional medicine and thus are using an integrative medicine approach. The remainder of this chapter is a user-friendly guide to MS-relevant CAM therapies for clinicians. Therapies are listed in alphabetical order, and the emphasis is on concise presentation of safety and efficacy information that can be quickly conveyed to MS patients who are using, or considering, these therapies. A brief summary in bolded italics is included at the end of each section. Table 9.2 provides a listing and risk–benefit summary for the specific CAM therapies that are covered in this section. Table 9.2 Risk–Benefit Profiles of MS-Relevant CAM Therapies Traditional Chinese medicine (TCM) is an ancient, multimodal healing method. One component of this broad-based therapeutic approach is acupuncture. There are multiple other components, including herbs, nutrition, tai chi, exercise, stress reduction, and massage. There are remarkably few studies of TCM in MS. Clinical trials of acupuncture for alleviating MS symptoms are too limited to be conclusive. In other conditions, acupuncture appears to relieve pain as well as nausea and vomiting. Although Chinese herbal medicine is sometimes touted as being effective for MS, there are actually no rigorous studies of this therapy in MS. Acupuncture is usually well tolerated when done by a well-trained acupuncturist. In contrast, it is not known if Chinese herbal medicine interacts with conventional MS medication or if it is safe to use in those with specific medical conditions, including MS. Of concern, activation of immune cells, especially T cells and macrophages, may be caused by several commonly used Chinese herbs, including Asian ginseng, astragalus, and maitake and reishi mushrooms. This raises the theoretical risk that these herbs could worsen the disease course of MS or antagonize the therapeutic effects of immune-modulating and immune-suppressing medications. In summary, acupuncture is generally safe and, though not well studied in MS, may alleviate pain. In contrast, Chinese herbal medicine, another component of TCM, has theoretical risks and is of unknown efficacy in MS. Free radicals cause cellular injury through oxidative damage. This oxidative damage may be decreased by antioxidant compounds. In MS, oxidative damage may play an important role in myelin and axonal injury, and thus, it is sometimes claimed that antioxidants should be used to treat MS. In the animal model of MS (experimental allergic encephalomyelitis (EAE)), multiple antioxidant compounds have produced therapeutic effects. Small, short-term MS clinical trials with various antioxidants suggest that these approaches are well tolerated. However, these studies have not generally been powered adequately to assess efficacy. Many antioxidants activate immune cells, including T cells and macrophages. As a result, antioxidant compounds carry theoretical risks of worsening MS or antagonizing the effects of disease-modifying medications. However, as noted, the limited clinical trials to date indicate that antioxidants are generally well tolerated in MS. On the basis of theoretical and animal model studies, antioxidants could produce therapeutic effects in MS. However, there is no definitive evidence for their efficacy in MS, and there are theoretical risks associated with their use in MS. Apitherapy is a term used for various unconventional treatments that utilize bees and bee products. One form of apitherapy that is sometimes claimed to be beneficial for MS is bee venom therapy (BVT), which involves the regular use of bee stings that are produced by placing bees on specific body parts with tweezers. The highest quality study of BVT in MS is a randomized, crossover study of 26 patients with secondary progressive or relapsing–remitting MS. In this clinical trial, BVT did not produce any significant treatment effect with multiple outcome measures, including attack frequency, neurological disability, MRI activity, fatigue, and overall quality of life. Although BVT is generally safe, there are rare adverse effects. Bee stings may rarely cause anaphylaxis, and thus, EpiPen devices should be available when this therapy is being used. In addition, some information on the use BVT for MS recommends bee stings around the eye as a treatment for optic neuritis. However, periorbital bee stings may actually cause optic neuritis and thus should be avoided. In conclusion, BVT has not been shown to produce any significant therapeutic effects in MS. It is generally well tolerated but may rarely cause serious side effects. Cooling is an unconventional treatment that utilizes the known temperature sensitivity that occurs in MS. For more than 100 years, it has been recognized that small increases in body temperature (0.5°C) may provoke MS symptoms and, likewise, that small decreases in body temperature may relieve symptoms. On the basis of this observation, various cooling methods have been developed. These methods range from simple, commonsense strategies, such as drinking cold beverages and staying in air-conditioned areas, to more complex approaches, such as wearing specially designed cooling garments. Several studies of variable size and quality have reported that cooling garments alleviate multiple MS symptoms. To rigorously follow up on these findings, a randomized, controlled, blinded trial of cooling in MS was conducted. This study found that cooling was associated with objective improvement in walking and visual function. Subjectively, there was improvement in strength, fatigue, and cognition. The therapeutic effects of cooling may be greater in those who are known to experience heat sensitivity. Cooling strategies are generally well tolerated. Cooling may provoke worsening in a small subset of MS patients who are cold sensitive. Cooling garments may be awkward and cumbersome. At the onset of cooling, some people may experience mild discomfort. Cooling is low risk and may relieve multiple MS symptoms.
Complementary and Alternative Medicine: Risks and Benefits
Introduction
Terminology
Natural products
Herbs, vitamin, and mineral supplements
Mind and body medicine
Guided imagery, meditation
Manipulative and body-based practices
Massage, reflexology
Movement therapies
Pilates, Alexander technique
Traditional healing
Native American medicine
Energy medicine
Healing touch, magnet therapy
Alternative medical systems
TCM, Ayurveda
Unconventional medicine use
CAM Therapy
Risk–Benefit Profile
Acupuncture, Chinese herbal medicine, and traditional Chinese medicine
Low risk and possible symptomatic effects for acupuncture, theoretical risks and no known efficacy for Chinese herbal medicine
Antioxidants
Theoretical risks, no known efficacy
BVT
Rare risks, no known efficacy
Cooling therapy
Low risk, multiple possible symptomatic effects
Cranberry
Low risk, possible preventive effect on UTIs
Diets: the Swank diet and related diets
Low risk, possible disease-modifying effect
Echinacea and other immune-stimulating supplements
Theoretical risks, no known efficacy
Ginkgo biloba
Low risk, possible symptomatic effects on fatigue and cognition
Guided imagery
Low risk, multiple possible symptomatic effects
LDN
Low risk, multiple possible symptomatic effects
Marijuana (cannabis)
Moderate risk, possible disease-modifying and symptomatic effects
Massage
Low risk, multiple possible symptomatic effects
Reflexology
Low risk, multiple possible symptomatic effects
Tai chi
Low risk, multiple possible symptomatic effects
Vitamin B12
Low risk, therapeutic effects in those who are vitamin B12 deficient
Vitamin D
Low risk, definite effect on bone health and possible disease-modifying and symptomatic effects in MS
Yoga
Low risk, possible symptomatic effect on fatigue
CAM therapies
Acupuncture, Chinese herbal medicine, and traditional Chinese medicine
Antioxidants
Bee venom therapy
Cooling therapy
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