PRESENTING: Integrative Medicine for Parkinson s Disease: What the Health? BY: Lisa W. Corbin, MD, FACP Medical Director, Center for Integrative Medicine University of Colorado Hospital Associate Professor, Internal Medicine University of Colorado School of Medicine Definitions Outline Low hanging fruit making the most of lifestyle approaches Risks / benefits of CAM in general CAM therapies to consider with PD (Time permitting) Center for Integrative Medicine Definitions CAM (Complementary / Alternative Medicine) Therapies not historically associated with US hospitals or medical schools Acupuncture, Massage Therapy, Chiropractic Lifestyle medicine Use of stress reduction, exercise, nutrition, good sleep for health benefits Integrative Medicine Lifestyle approaches and CAM therapies coordinated with conventional onal medical treatments Using an Integrative Approach Avoid harmful practices Focus on lifestyle / self-care Sleep Exercise Nutrition Mind / body techniques Discuss safe, plausible CAM therapies Acupuncture Massage Chiropractic Herbs / supplements
Harmful CAM Therapies Colonic hydrotherapy Chelation therapy Ionic foot baths IV therapies Restrictive diets Megavitamins Some herbs / supplements Direct toxicity Indirect: drug interactions Stimulate tumor growth, immune system Anything used IN PLACE OF proven, curative, conventional treatments Using an Integrative Approach Don t use harmful practices Focus on lifestyle / self-care Sleep Exercise Nutrition Mind / body techniques Consider safe, plausible CAM therapies Acupuncture Massage Chiropractic Herbs / supplements Why Lifestyle Approaches? Give you control over your health and an active role in your care Low / no cost Can help current conditions related to PD Help prevent and treat other common conditions Hypertension, weight gain, cancers, heart disease, high cholesterol Get Some Sleep! Restorative sleep improves pain, fatigue, mood Poor sleep links: breast cancer, weight gain, chronic pain Behavioral approaches: Don t eat, drink, exercise just before bed Avoid late day caffeine, excess alcohol Get consistent exercise earlier in the day Pay attention to room environment Establish consistent sleep times Get out of bed if not tired Don t nap
Exercise: Highlighted Uses Improves sleep, mood, anxiety thus improving overall general health For PD Helps balance, strength, quality of life, mobility, energy, mood, motor function May slow progression Brisk walks, swimming / water aerobic exercise; stretching / strength / flexibility Don t forget other benefits! Improved cholesterol, weight, BP, DM, BMD Decrease pain Decrease hot flashes Reduction in breast cancer Improvement in immune function Simple Exercise Prescription: FIT F requency Exercise every day I ntensity Break a sweat; increase difficulty T ime Start with 5 minutes daily, increase by 1 minute daily each week; goal 30 minutes Yoga & Tai Chi Multicenter trial to determine if exercise slows PD progression Funded by the National Institutes of Health (NIH) First step: Define the right intensity of exercise Comparison of aerobic exercise at 2 intensities to no exercise People recently diagnosed with PD; not on medications for PD Yoga decrease pain / rigidity Tai Chi for balance Inexpensive classes in metro Denver (see PAR website)
Tai Chi 195 subjects with mild to moderate PD Twice weekly tai chi vs resistance vs stretching for 6 months Lower incidence of falls (vs stretching group) Improvement in balance and postural stability Improvement in stride length and reach (vs resistance or stretching) Benefits maintained 3 months after instruction ended Safe Li F. et al. NEJM 2012;366:511 Tango Dancing Studied short term with good effects 12 month twice weekly 1 hour classes 62 patients; evaluated off medication at 3, 6, 12 months Improvements in all measures suggested disease modifying effects Control group w/o change Irish dancing 24 people; 90 min weekly x 6 months Improved freezing, gait, balance more than PT; both groups improved in all other physical measures Duncan RP. Neurorehab Neural Repair 2012 Volpe D. BMC Geriatrics 2013 Singing Helpful for combating decreases in voice strength and facial expression Fun! Local and national groups Nutrition in 7 Words Young. Clinical Nurse Specialist 2012 Trembleclefs.com
Real Nutrition Questions Herbs and Supplements Three types of medicines: Prescription (Rx) Over-the-counter (OTC) Dietary supplements and herbs Unlike Rx and OTC, supplements: Are not required to prove safety, efficacy Burden of proof on FDA to show unsafe Are not required to enforce quality control GMP required 2011, burden of proof on FDA Can vary in concentration of ingredients
Coenzyme Q10 Antioxidant; heart protection Patients with PD deficient in CoQ10 vs age / gender matched controls (and not in 4 other antioxidants) Two large randomized trials contradictory 80 people: placebo, 300 mg / d, 300 mg 2x / d, 300 mg 4x / d for 16 months or until needed l-dopa; benefits significant at highest dose 600 people on stable l-dopa: placebo + 1200 IU vitamin E, 1200 mg CoQ10 + vitamin E, 2400 mg CoQ10 + vitamin E no differences Safe Creatine Early studies suggested possible role for this muscle building protein RCT underway in 1741 early (< 5 years of l-dopa) PD patients 10 gm creatine 3 x / day, at least 5 years (enrolled 2007 2010) Safe unless kidney disease Mischley et al. J Neuro Sciences 2012 Shults CW et al. Arch Neurol 2002 NCT00740714 clinicaltrials.gov 2011 Elm JJ. Mvmt disor 2012 Caffeine Coffee, green tea, black tea Epidemiologic studies associate increased caffeine intake with decreased risk of PD No interventional studies Other supplements 800 patients Selegiline, vitamin E (2000 IU), placebo, or selegiline + vitamin E Time until need for l-dopa Selegiline was effective; vitamin E did not work Other studies with safety concerns for vitamin E NEJM 1993 Ann Int Med 2005
Mind-body Stress / anxiety make thinking and functioning more difficult Therapies can help cognitive changes, mood, sleep, pain, fatigue Mind-body therapies are safe, often covered by insurance Mind-body Cognitive Behavioral Therapy Relaxation / breathing Biofeedback / heart math Art, music, pet therapy Mindfulness / Meditation Imagery / visualization Yoga / tai chi Hypnosis Mind-body Details Typically meet with therapist 5 10 visits You need to practice at home Not all therapists comfortable with all methods Often covered by insurance
Acupuncture Chinese Medicine Background Health = balance of yin and yang Qi = energy force created by interaction of yin and yang Excess, deficiency, or stagnant flow of qi results in disease Examples of TCM diagnoses: Yin deficiency and yang predominance with reduced kidney qi Stomach qi rebelling Acupuncture Western Medicine Background William Osler, 19 th century: best treatment for lumbago James Reston, China, 1971 Biological effects Local nerve activation Feel good chemicals: Endorphins, enkephalins, serotonins, natural opioids Anti-inflammatory: ACTH Functional brain scanning Acupuncture for PD Systematic review: 4 RCT of scalp acupuncture for PD motor symptoms 2 showed benefit, 2 did not; quality of trials low Consider for associated symptoms Fatigue (study at UCH) Balance Constipation Pain Anxiety / depression Acupuncture for Fatigue Study Funded by Michael J Fox Foundation PI: Benzi Kluger, MD (UCH) For people living with PD affected by moderate to severe fatigue Age 40 or over, on stable medications Not experiencing dementia Acupuncture vs control 2x / week for 6 weeks Enrollment concluded 2013; data analysis currently Hun-Soo L. Chin J Integ Med 2013
Chinese Herbals Used extensively in China and in TCM Protocol described randomizing 160 pt with early PD and 160 pt with moderate PD to a specific TCM herbal +/- medications to begin in 2013, in China Zhang J. J Integr Med 2013 Massage Therapy Developed by almost all cultures Many different forms Emphasis on improving circulation, releasing muscle tension, calming and relaxing patient Massage Therapy: Uses in PD Relaxation, improved QOL Pain management Improved shoulder mobility and increased walk speed Few studies; case series in 2012 showed benefit after one 30 min session Improved sleep Donovama N. J Alt Comp Med 2012
Chiropractic: Some Uses Back pain Neck pain Headaches NO proof for prevention or maintenance Not studied in PD Finding a Good Practitioner Training and licensure Experience with condition Expected benefits Risks Direct risks or side effects, interactions? Costs / reimbursement Time frame / progress assessment Ability to work with conventional providers Be wary of therapists that claim to cure illness What the Health! Integrative medicine coordinates CAM and lifestyle approaches with conventional care Explore lifestyle approaches Don t use harmful CAM therapies Use beneficial, safe therapies Consider plausible, safe therapies Find good practitioners Use reliable information sources Summary Exercise aerobic; consider tai chi or dance; attend the next session on exercise! Nutrition Increase fiber and water to help constipation Avoid large, high fat meals (better medication absorption) Restrict protein if advanced disease with motor fluctuations Supplements: CoQ10 still possibly helpful; safe Mind / body can be helpful for chronic illness Acupuncture Data not great for PD; trial of 3 5 weekly visits can determine if you feel it is helpful for you Can help other symptoms Massage: again, you can be your own trial!
Other UCD PD Studies TMS and Cognition: To determine if transcranial magnetic stimulation may improve thinking and memory in people with PD and no dementia FS-Zone: For PD patients taking only rasagaline (azilect) or selegeline to determine if pioglitazone may slow PD progression Be open minded, but not so open minded that your brains fall out Widely attributed Research Resources Fox Trial Finder: https://foxtrialfinder.michaeljfox.org/register/ PD trials: www.pdtrials.org/ National Parkinson s Foundation: http://www.parkinson.org/ PAR: http://www.parkinsonrockies.org/patients/tre atments/clinical-trials Internet resources General CAM resources: National Center for Complementary / Alternative Medicine: nccam.nih.gov UCD Health Science Library s Strauss-Wisneski Complementary and Indigenous Medicine Collection the website has links to other resources and journals and books held in the collection: http://hslibrary.ucdenver.edu/strauss Mayo Clinic: http://www.mayoclinic.com/health/parkinsonsdisease/ds00295 ;
Herbal / Supplement resources: USP Dietary Supplement Verification Program www.usp.org/uspverified/dietarysupplements NIH information on supplements: http://ods.od.nih.gov Acupuncture National Certification Commission for Acupuncture and Oriental Medicine: http://www.nccaom.org Massage American Massage Therapy Association: www.amtamassage.org Parkinson s Specific: Exercise: www.parkinson.org/parkinson-s- Disease/Treatment/Exercise/Exercise-Tips.aspx Supplements: http://www.parkinson.org/parkinson-s- Disease/Treatment/Complementary-Treatment Nintendo Wii: http://www.parkinson.org/nationalparkinsonfoundat ion/files/cd/cdf0b319-a28b-4082-bf07-64888dbd2c90.pdf Chiropractic American Chiropractic Association: http://www.acatoday.org
The Center for Integrative Medicine University of Colorado Hospital Anschutz Medical Campus 720-848-1090 www.uch.edu/integrativemed General Assessment / Overview Lisa Corbin, MD Tish Bolshoun, PA Traditional Chinese Medicine Daisy Dong, LAc Nancy Ngyuen, LAc Ban Wong, LAc MK Christian, LAc Geina Horton, LAc Massage therapy Ann Mathews, CMT Heather Spencer, CMT Rose Patch, CMT Darci Gau, CMT Nutritional Counseling Colleen Gill, RD Lacey Patton, RD Pharmaceutical / Herbal Consults Monika Nuffer, Pharm D Chiropractic Brian Enebo, DC Behavioral Medicine / Biofeedback Denise McGuire, PhD Carrie Payne, PsyD Justin Ross, PsyD Liesel Hunter, PsyD Referrals Access to Services Self referred UCH physician or provider referred Outside physician or provider referred Insurance / authorizations checked Visits scheduled With specific practitioner, and / or With MD or PA to discuss lifestyle and self-care approaches in depth, explore CAM options and make a personalized plan Integration of Care Notes for each visit available in electronic health record, viewable by other UCH care providers Referral letter written to physicians, other providers Visit summary for patient Formal case reviews Integrates the care from within TCFIM Further integration with other care providers