This Way In: New Guideline for Alternative and Complementary Medicine for Multiple Sclerosis

Neurology Now
April/May 2014
Volume 10(2)
p 12–13
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According to the National Institutes of Health, almost 40 percent of adult Americans use complementary or alternative medicine (CAM). Americans spent $33.9 billion on CAM in 2007 alone, according to the Centers for Disease Control and Prevention. People with multiple sclerosis (MS) are even more likely than the average American to avail themselves of CAM, with some studies estimating their CAM usage as high as 80 percent.

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MS is an inflammatory disease of the central nervous system that causes a wide range of symptoms—from mild to debilitating. These symptoms can include fatigue, muscle stiffness and pain, cognitive impairment, difficulty balancing or walking, blurred vision, and tingling or burning sensations not unlike pins and needles.

WHAT IS COMPLEMENTARY AND ALTERNATIVE MEDICINE?

CAM includes the enormous range of nonconventional therapies, supplements, and practices that claim to alleviate symptoms of a disease or to improve health. They may be used in addition to (complementary) or instead of (alternative) physician-recommended therapies.

Some CAM therapies are recommended by physicians, as enough evidence has accumulated to support their use. Folic acid supplementation is often prescribed to pregnant women, and many neurologists recommend vitamin D supplementation for people with MS. Exercise is regularly prescribed by physicians to help improve the symptoms of several neurologic conditions, including MS. Hospitals often incorporate massage therapy, meditation, and visualization techniques to alleviate pain or help with rehabilitation.

Because so many CAM treatments are available and so many MS patients use them, the American Academy of Neurology (AAN) convened a panel of experts to review studies of CAM therapies in MS, evaluate those studies based on the strength of their evidence, and issue a guideline for physicians and patients. Medical evidence should be based on large studies that include many people. When appropriate, the studies should be “double-blinded,” which means neither the researchers nor the participants know who is receiving the actual treatment and who is receiving a placebo. In addition, studies should be “randomized,” which means that participants are assigned randomly (in a sense, by coin toss) to receive either the treatment or a placebo. The effects of the treatment should be clearly measured and not left to interpretation by the researchers. If more than one study produces similar results, the treatment recommendation is considered even more reliable.

The goal of the CAM in MS guideline was to draw attention to the existing evidence for the effectiveness or ineffectiveness of CAM therapies and to highlight the need for more rigorous studies into the safety and efficacy of CAM, according to lead author Vijayshree Yadav, M.D., associate professor of neurology and clinical director of the MS Center at Oregon Health and Science University in Portland.

EVIDENCE FOR CAM THERAPIES' EFFECTIVENESS IN MS

The key message of the guideline, according to Dr. Yadav, is that “right now, there is little evidence for the effectiveness of most CAM therapies we evaluated.” (To read a Patient Page from the American Academy of Neurology on the guideline, go to bit.ly/1cuzlVF.)

“In addition, we found that studies of the safety of CAM treatments were limited and that the long-term safety of CAM treatments is unknown,” Dr. Yadav adds. Furthermore, very little data are available on how CAM therapies interact with conventional therapies or what the long-term effects of many treatments are.

However, lack of proof that a treatment is effective is not the same as proof that the treatment is ineffective. Future studies may offer more evidence one way or the other. “It's clear that we need much more research in the field,” Dr. Yadav says.

CAM VERSUS CONVENTIONAL MEDICINE?

Barbara S. Giesser, M.D., a neurologist at University of California at Los Angeles' Reed Neurological Research Center and a Fellow of the AAN, says many of her patients use CAM therapies. “I have seen patients' symptoms improve with some CAM therapies when they are used in addition to the conventional treatments or for specific symptom alleviation. If they are not harmful to patients, I have no problem with them,” Dr. Giesser says. However, she does caution against hot yoga, as MS patients can be sensitive to heat.

Both Drs. Yadav and Giesser are wary of CAM therapies with unknown side effects or unknown ingredients. “It's quite common for a patient to tell me he is taking a supplement but that he has no idea what it contains or whether the claims made by the manufacturer are supported by scientific evidence,” Dr. Giesser says. Also, supplements might interact with disease-modifying therapies or other drugs prescribed for symptom management, she says. “I'm pleased that the AAN has reviewed the available literature and concluded that more studies are needed,” Dr. Giesser notes.

It is vital for patients and physicians to distinguish between disease-modifying therapies and symptom-alleviating therapies, both doctors say. Disease-modifying therapies positively affect the course of the disease, whereas symptom-alleviating therapies offer relief for specific symptoms of a disease. “I don't know of any CAM treatments that affect the course of MS. So whether or not they use CAM, patients should not stop using the FDA-approved drugs that have been proven in clinical trials to reduce inflammation and relapse and slow the progress of the disease,” Dr. Giesser says.

Disclosures: Dr. Yadav serves as a section editor for Current Neurology and Neuroscience Reports; served as consultant for Bayer Healthcare Pharmaceutical; is on the speakers' bureau of Novartis; receives research support from the McDougall Foundation, National Multiple Sclerosis Society (NMSS) Foundation, Nancy Davis Center Without Walls Foundation, Biogen Idec; and has received travel funding from the Neurological Society of India. Dr. Giesser has received support in the form of equipment to conduct a trial of a cooling device from Avacore Technologies and her husband has stocks in Biogen Idec.

CAM Therapies Shown to Be Effective

Ginkgo Biloba: This supplement is possibly effective for the relief of fatigue in MS, the guideline authors found. “However, we don't have a good handle on how ginkgo biloba alleviates this symptom,” Dr. Yadav says.

Cannabis: The panel reviewed 20 studies on the effects of cannabis in different forms. “It is important to note that most of the clinical trials involved standardized derivatives of cannabis or synthetic forms of cannabis not currently approved by the FDA for use in MS,” Dr. Yadav says.

Also, cannabinoids have a potential for adverse cognitive or psychological effects, such as confusion and anxiety, and the long-term side effects of cannabis use are not known at this time.

Oral cannabis extract (OCE) and tetrahydrocannabinol (THC) were found effective for patient-reported spasticity and pain in the short term, the guideline authors found. (Spasticity is a term for muscle stiffness and rigidity, a common and sometimes disabling symptom of MS.) OCE and THC were also found to be probably ineffective for alleviating tremor, but they are possibly effective for spasticity and pain in the long-term.

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Sativex oromucosal cannabinoid spray, an oral spray available in Canada and some European countries but not available in the United States, is probably effective for short-term patient-reported spasticity, central neuropathic pain, and urinary frequency, according to the guideline.

(Smoked cannabis had too little data available to support or determine its safety or efficacy when used for spasticity, pain, balance and posture, and cognition.)

Reflexology: This CAM treatment, which involves applying manual pressure to points on the feet, is possibly effective for MS-related paresthesia, the guideline authors found. Paresthesia is similar to pins and needles; a person with MS may feel burning, prickling, or itching sensations on the skin. Dr. Giesser says that this is one CAM she would consider prescribing as an alternative to conventional treatments in cases where the conventional treatments have adverse side effects for a patient.

Magnetic Therapy: The guideline authors found that magnetic therapy is probably effective for fatigue, a common symptom of MS. In magnetic therapy, patients are exposed to low frequency, pulsed electromagnetic fields on a regular basis. In one study, patients lay on an electromagnetic mat for 8 minutes twice a day for 12 weeks. It is unclear how magnetism works to relieve fatigue, but it has few side-effects and is regarded as relatively benign.

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