Complementary Alternative Therapies in PD Rima Ash, MD Kaiser Permanente 10/09/14

Complementary Alternative Therapies in

PD

Rima Ash, MDKaiser Permanente10/09/14

Overview

• Dance

• Exercise: not covered today

• Tai chi/qi gong

• Yoga

• Acupuncture

• Supplements/Herbal remedies

Go Dancing!!!19 Parkinson’s patients were given either 20 exercise classes or 20 tango classes

The exercise class consisted of one hour of movement, much of it in chairs or using chairs for support.

The tango class was more vigorous, and focused on stretching, balance, footwork and timing.

Both groups showed improvement, but only the tango students did better with balance

The rhythm of music helps you move!The Journal of Neurologic Physical Therapy. Madeleine E. Hackney et al.

Dance• Several trials for Dance and PD have shown

improvements in gait, balance, posture, and coordination • Hackney ME, Earhart GM. Effects of dance on gait

and balance in Parkinson's disease: a comparison of partnered and non-partnered dance movement. Neurorehabil Neural Repair. 2010;24:384-392.

• Duncan RP, Earhart GM. Randomized controlled trial of community-based dancing to modify disease progression in Parkinson disease. Neurorehabil Neural Repair. 2012;26:132-143.

• Heiberger L, Maurer C, Amtage F, et al. Impact of a weekly dance class on the functional mobility and on the quality of life of individuals with Parkinson's disease. Front Aging Neurosci. 2011;3:14.

Mark Morris dance video

Bay Area Dance classes

• SF: [email protected] or call 415-285-7377

• Marin: (415) 819-2066 or email [email protected]

• East Bay: [email protected]

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Tai Chi and Qigong

Tai chi:

• Patients randomized to Tai Chi vs resistance training/stretching for 1 hour 2x/wk over 24 wks

• The Tai Chi group did better with stability and overall balance

• Li F, Harmer P, Fitzgerald K, et al. Tai chi and postural stability in patients with Parkinson's disease. N Engl J Med. 2012;366:511-519.

Qigong (breath/energy work):

• 32 patients received 90 min/wk of Qigong for 2 months

• 24 patient received no therapy

• At 3,6, and 12 months- the Qigong group improved in motor and non-motor areas

• Schmitz-Hubsch et al., Movement Disorders. 2006 April 21 (4), 543-548



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Yoga and Parkinson’s disease

• Yoga can help with balance and stiffness by building flexibility and strength

• Yoga brings mindfulness to your movements• Yoga Journal, February 2007, p92 • International Journal of Yoga Therapy,

No.15 (2005), p81.



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A Report from the Inside: H. Paul Zeiger, Ph.D. Yoga Instructor and PD patient

• On yoga, PD, and Handstands

• “With careful work and the addition of PD medications, I got this pose back”

• This example shows how yoga and medical treatment can work together

• It also illustrates the role of yoga as a diagnostic tool: “my recovery of the pose indicated that the medication was working”

Acupuncture• Yeo, S., Lim and team used fMRI to measure

the effects of acupuncture point GB34 (Yanglinqquan) on specific brain areas affected by Parkinson's Disease

• Small sample size of 12 healthy controls and 12 people with PD

• Acupuncture of GB34 improved neural responses in the the basal ganglia

• JAMA (Journal of the American Medical Association) in September 2012

Bee Venom Acupuncture

• A subcutaneous injection of diluted bee venom at an acupuncture point

• Aimed at enhancing and prolonging the effects of acupuncture points

• Thought to have anti-neuro-inflammatory effects

• 35 patients (13 in the acupuncture group, 13 in the bee venom acupuncture group, and 9 in the control group)

• Treatment was repeated twice a week for 8 weeks.

• Participants in the bee venom acupuncture group showed significant improvement in motor scores, balance, and walking time.

• In the acupuncture group, motor and depression scores improved significantly.

• The control group showed no significant changes in any outcome after 8 weeks

Herbal Medication

• Chinese medicines used for tonifying the kidney, such as Herba Epimedii may help PD by preventing dopaminergic cell death

• Epimedii: barrenwort, bishop's hat, fairy wings, horny goat weed, rowdy lamb herb, randy beef grass or yin yang huo

• May help Erectile Dysfunction as well


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Herbal Medications• Vicia faba

(broad or fava bean)

Contains levodopa

Rich in tyramine and should be avoided if taking MAO inhibitors

Can cause anemia in specific patients with G6PD deficiency

Mucuna Puriens(cowhage or velvet

bean) Contains levodopa

Used in Ayurvedic medicineNo data on long-term side effects,

effectiveness, or tolerability

Contains serotonin and nicotine

Mucuna Puriens

Mucuna pruriens in Parkinson’s disease: a double blind clinical and

pharmacological study. R Katzenschlager et al. J Neurol Neurosurg Psychiatry

2004;75:1672-1677 doi:10.1136/jnnp.2003.028761

Mucuna puriens• Patients were given either 50/200 mg of

Sinemet, 15 g Mucuna, or 30 g Mucuna

• Patient were tested using the UPDRS at baseline, and 4 hours after medication administration

• Results• The 30 g Mucuna dose led to a

considerably faster onset of effect when compared to Sinemet• 34.6 v 68.5 min

• Mean on time was 37 min longer with 30 g mucuna than with Sinemet

• No significant differences in dyskinesias or tolerability occurred



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Glutathione• An antioxidant that may

be reduced in PD

• 1996, 9 patients with early, untreated PD were given IV glutathione 600mg twice/day for 1 month • All improved

significantly even after therapy was discontinued

• 2009, 21 patients with PD studied• No side effects or

improvements seen

Creatine

• 1740 subjects were assigned to take either 5 grams of Creatine or a placebo twice per day for at least 5 years

• The National Institute of Health (NIH) announced in September 2013 that they were stopping the study because of lack of benefit

coq10

• Mixed reviews

• Smaller studies using 1200 mg showed that coq10 may slow down progression of disease

• A larger study run by the NIH enrolled 600 patients and used doses of 1200mg/day and 2400mg/day for up to 16 months of treatment. • No benefit was seen in this larger study

Caffeine

• 200 mg twice daily for 3 weeks improved daytime somnolence and severity of motor symptoms when compared with placebo.

• There were no improvements in quality of life, depression, or sleep quality

• Postuma RB, Lang AE, Munhoz RP, et al. Caffeine for the treatment of Parkinson's disease: a randomized controlled trial. Neurology. 2012;79:651-658.

Vitamin E

• An antioxidant

• 2000 units daily have been shown to reduce rate of cognitive decline in those with MCI or Alzheimers Dementia

• In PD, Vitamin E has not demonstrated a slowing effect or neuroprotection• Trial did show potential harm to PD

patients causing increased bleeding risk

B12• As people age, they may develop difficulty

absorbing B12 from the gut, even if the amount in their food sources is adequate

• Oral supplements (usually 1000 mcg) may help, although persons with severe B12 absorption problems or deficiencies may require injections

• There are some theories that Sinemet ma lower B12 levels

• This may lead to memory loss

Ginger

• Helpful for Nausea

• Zingerone: a compound found in ginger root• Showed a protective effect on

dopamine-containing neurons in a mouse study (Kabuto H 2005).

St Johns Wort (Hypericum

Perforatum)• Similar to serotonin re-uptake inhibitors (SSRIs).

• It may be effective in mild to moderate depression

• Most commonly used dose is 300 mg three times daily.

• In one study of Hypericum Perforatum in a mouse model of PD, there appeared to be some inhibition of the effect of the toxin (MPTP) used to cause Parkinsonism.

• Do not take if on MAO-B inhibitors (Azilect/Selegeine), other antidepressants, blood thinners such as aspirin, heparin or warfarin (Coumadin)

Sleep

• Melatonin 3-6mg 1-2 hours prior to bedtime

• Valarian root: Valerian root has sedative and anxiolytic effects• Dosage is difficult to determine, due to

the lack of standardization for supplements

• Doses of 400–900 mg taken from 30 minutes to two hours before bed have shown benefit

Constipation

• Many herbal laxatives and "dieter's teas" are stimulant laxatives.

• Rhubarb, Aloe, Senna, Buckthorn



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Supplements-Natural is not

always safe!• Dangerous drug

interactions

• Serious side effects

• Unknown Purity of contents

• Can be very Expensive

Documents

Complementary Alternative Therapies in PD Rima Ash, MD Kaiser Permanente 10/09/14