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MS information for health and social care professionals Complementary and alternative medicine

What is CAM?

Complementary and Alternative Medicine (CAM) refers to 'those forms of treatment which are not widely in use by orthodox healthcare professionals', to use a definition from the British Medical Association[1]. A more recent definition of complementary medicine[2] is "diagnosis, treatment and/or prevention which complements mainstream medicine by contributing to a common whole, by satisfying a demand not met by orthodoxy, or by diversifying the conceptual frameworks of medicine". There is an unfortunate tendency to lump all non conventional practices together as alternative and to label them all as either 'good' or 'bad', depending on preference. This is, of course, absurd. There are approaches which bring health benefits to particular individuals on both sides of a dividing line. The whole difficulty is that there is no very clear way of knowing in advance just which people will benefit from which therapy. Health professionals do what they can with the tools they think they know are appropriate for the suffering presented to them. The more tools that are known, the greater the likelihood of helping more people more appropriately. Someone who only knows, for example, homoeopathy is as limited (or more so) as someone who only knows conventional treatment. It is perhaps the task of medicine over the next few decades to integrate CAM therapies into treatment pathways, always remembering that the prime goal must be to alleviate suffering and not to become too wedded to exactly how this is achieved.

Which therapies?

What does this mean for the person with MS? There are a number of CAM therapeutic approaches which are sometimes helpful in the treatment of MS, either as single treatments (alternative) or additional treatments (complementary). There are some studies which help to indicate just who may benefit, but since there has been very little funding of research into most CAM, anecdote has a strong role.

The field of CAM has raised some very interesting questions about what is meant by evidence. In this climate of evidence based medicine, the gold standard of meta-analysis of multiple clinical trials and, at least, randomised controlled trials against placebo are held up as the only clear way of deciding if a treatment is helpful or not, and therefore perhaps whether funding should be devoted to it. Therapies with this kind of evidence base of efficacy in MS include nutritional therapy, massage, body work, reflexology, neural therapy, imagery and psychological counselling. These were systematically reviewed by Huntly and Ernst[3].

Therapies with anecdotal support for benefit in individuals with MS include: acupuncture, aromatherapy, yoga, hyperbaric oxygen therapy and homoeopathy.

Use of CAM in MS

The use of CAM is very widespread in people with MS. One study[4] in the United States reports 44% using physical therapy, 38% using nutritional therapy, 38% using massage and 31% using counselling. In addition, 31% of all those surveyed were using homoeopathy, acupuncture or removal of mercury amalgam fillings. A 1994 survey in which 100 members of the Dutch MS Society were interviewed by telephone[5], found that 26% were currently using CAM and that 42% had used it in the past. A German survey in 1997[6] surveyed 129 MS patients and found that 64% had used a form of CAM with at least 87 therapies having been tried overall. Some people were using up to nine different modalities. A more recent Italian study[7] of 109 consecutive ambulatory outpatients with at least a three year diagnosis of definite or probable MS, found that 35.7% had used at least one CAM therapy once. A perceived benefit was recorded in 67% of cases and the mean yearly cost per person for CAM, was 483 Euros. It seems sensible at least to begin to understand what is going on here. What do people hope to achieve with all this CAM usage and what do they actually achieve?

In most cases, health professionals are unaware that CAM is being used by those they are treating. A well known general survey of CAM use in the United States[8] showed that although 42% of the sample of the general population (n=2055) admitted to the use of a complementary or alternative therapy in the previous 12 months, only 38.5% had divulged its use to their physician. In the Italian study of MS patients referred to above, the caring general physician was not aware of the CAM use in 67% of cases and the caring neurologist was unaware in 82% of cases. This suggests that a large number of people with MS, unbeknown to the health care professionals whom they consult, are using therapies of which many health professionals have very little understanding or knowledge.

Therapies with some conventional evidence of efficacy in MS

Nutritional therapy

There have been many attempts to link dietary pattern and the geographic distribution of MS. It appears that diets high in gluten and milk are much more common in areas with a higher prevalence of MS, but most interest has centered around the role of dietary fat. The most well known approach is the Swank Diet, recommended by Dr R Swank since 1948[9]. He recommends a saturated fat intake of no more that 10g per day, a daily intake of 40-50g of polyunsaturated oils, at least a teaspoon of cod liver oil daily and a consumption of fish three or more times a week. An impressive cohort of patients was amassed and followed up for many years and very significant decrease in expected relapses and onset of disability was demonstrated. His studies have been widely criticised for lacking a control group and for inclusion criteria which are not particularly well defined and may perhaps reflect the milder end of the MS spectrum.

The emphasis on dietary fat was quite extensively investigated in at least three double blind studies using supplementation with linoleic acid[10,11,12]. The results of these studies were quite mixed, with two showing an effect and one not, but a combination analysis suggested that patients supplementing with linoleic acid had a smaller increase in disability and reduced severity and duration of relapses compared with controls[13]. There have been many discussions about these trials and the results are by no means unequivocally accepted. Some feel that the dose of linoleic acid used in these trials was perhaps rather too small. However, NICE guidelines recommend that 17-23g /day of linoleic acid may reduce disease progression. This amount may be consumed in many forms including full fat sunflower margarine or sunflower, safflower or sesame seed cooking oils.

Many people with MS supplement their diet with evening primrose oil or flax seed oil. Again there is debate about a reasonable dose, but on the whole it does seem that the evidence is fairly good that a diet high in some way in essential fatty acids is helpful in slowing the onset of disability in MS. The advice most commonly given by dieticians is to try to follow a 'healthy' diet with low saturated fat intake, increased intake of fish and lean meats, fresh vegetables and fruit and whole grain cereals.

Other supplements which have been suggested as possibly helpful are the antioxidants Selenium and vitamin E and the vitamin B12 and some pancreatic enzymes, on the grounds there is some suggestion of malabsorption in some people with MS. Another antioxidant extract sometimes used is Gingko biloba. This kind of dietary manipulation and supplementation is the kind of approach taken by Naturopaths. The literature is well reviewed by Murray and Pizzorno[14] and most particularly, by Bowling and Stewart[15].

Claims that food allergies may be present in MS have not been upheld by research. Private allergy testing is often expensive and real food allergies are rare in adults. However, if allergies are suspected, testing at an expert NHS centre is recommended.

It might be helpful to remember that a diagnosis of MS represents to many people a total loss of control. Through diet, control of the body can appear to be regained and in some cases therefore dietary manipulation is undertaken as much for psychological and emotional reasons as for any other.

Bodywork

The use of specific manipulative techniques such as chiropractic and osteopathy appears to be fairly widespread amongst people with MS, certainly in the 1996 United States study[4]. There are many other forms of bodywork where a therapist has a hands-on guiding role to the individual's limbs and muscles. There is no literature specifically about MS and the common forms of manipulation (osteopathy and chiropractic), but there is a single blind randomised controlled trial of Feldenkrais bodywork in multiple sclerosis[16]. The intent behind this approach is to reorganise the muscular and nervous system manually, which allows for improved functioning and promotes strength, flexibility and ease of movement. Sessions last about 45 minutes and focus on a particular movement pattern which may be problematic. The therapist tries to help identify what the patient feels and then expands the range of feeling to improve function. This approach is not unlike that of the Alexander Technique, another commonly used alternative therapy, perhaps more easily available than Feldenkrais in the United Kingdom.

The single blind trial recruited 20 individuals and used a cross-over design in which each received eight weeks of sham sessions followed by eight weeks of Feldenkrais sessions and vice versa. There were no changes in functional ability after the sessions, but there were significant differences in perceived stress, lowered anxiety and decreased depression scores. The authors comment that it is likely that the measures used in the study were not sensitive enough to capture the benefits of the Feldenkrais and in fact all of the participants were very positive about the bodywork and how it had helped them with the movement problem.

Psychotherapy and imagery

One study[17] followed 33 patients with MS and trained half of them in relaxation sessions involving the use of imagery, focusing on imagining the repair of damaged myelin and positive immune system responses. The control group followed their normal medical treatment. After a six week course of treatment, the imagery group had a significant decrease in anxiety but there were no changes in other psychological variables or in MS symptoms. The authors comment that this is a simple cost effective approach which can significantly reduce anxiety in people with MS.

There is one randomised controlled trial of group psychotherapy in MS[18] which was shown to be beneficial for those with mild to moderate depression, again with no change in disability scores.

Neural therapy

This is a technique using small quantities of local anaesthetic injected into specific areas of the body, principally old scars and areas that correspond to acupuncture points. It has been widely used in Germany and Austria since 1928, principally for problems arising from scars, but one double blind placebo controlled trial[19] investigated 21 patients with MS randomised into active (n=11) and placebo (n=10) groups. The active treatment was 1% lignocaine hydrochloride and placebo was 0.9% saline. Each patient received two treatments per week, consisting of injections at points into the ankles and also around the greatest circumference of the skull. There were no significant side-effects and on functional ratings with follow-up between two and three and half years there was overall long term improvement in 59%. Improvement rates were similar for all forms of MS. This is a cheap and sometimes extremely effective option. The Glasgow Homoeopathic Hospital has a number of patients who receive regular neural therapy sessions, many carrying on for several years.

Massage

Massage is very popular and anecdotally very helpful for some of the musculoskeletal symptoms of MS. It also appears to help general wellbeing. One study involved 24 patients with MS randomly assigned to either a 45 minute massage twice weekly for five weeks or to no treatment[20]. The massage group had significantly lower anxiety and a less depressed mood by the end of the study and had significantly improved in selfesteem, body image and image of disease progression. No conclusions however, were drawn about physical characteristics.

Reflexology

Reflexology involves stimulating points on the soles of the feet which are said to influence the physiology throughout the body. It has been investigated in MS on one occasion[21]. 71 patients were randomised to either reflexology treatment with manual pressure on specific points in the feet and massage of the calf area, or to nonspecific massage of the calf area only. 53 patients completed the study and there were significant improvements in the mean scores of paraesthesia, urinary symptoms, muscle strength and spasticity. This is an impressive result which warrants larger scale investigation.

CAM Therapies with anecdotal evidence of benefit for people with MS

Acupuncture

In its oldest form, acupuncture is a form of traditional Chinese medicine (TCM). Traditional Chinese physiology describes the running of energy ('Chi') in meridians which are said to course just below the surface of the skin over the whole body. The insertion of very fine needles into these meridians at pre-defined points is held to re-balance blocked or excessive energy flow and so cure symptoms. It is complicated to learn this sort of approach.

There is a simpler and more readily available Western form of acupuncture, which relies on the phenomenon that inserting a needle into a painful muscular trigger-point seems to deactivate the point and the pain which radiates from it.

There are very few controlled trials of acupuncture in MS. Clinical experience suggests that acupuncture is very helpful for some people, particularly in relieving cramps, spasms and bladder symptoms. One very small study[22] did suggest that acupuncture has a role in helping spasticity. Obviously more work is worthwhile in this area.

Aromatherapy

Six percent of 848 patients with MS who responded to a mail survey in British Columbia[23] used aromatherapy to help manage their condition. There are no scientific studies supporting the use of aromatherapy and it has been noted that since at least 23% of people with MS have an impaired sense of smell, the efficacy of aromatherapy may be questionable. There is no doubt though, that many people feel it is a worthwhile therapy, perhaps because of its effect on mood and its possible promotion of sleep. One author however[24] feels that aromatherapy cannot be recommended in the treatment of any form of neurological disease until more studies are available.

Yoga

Yoga uses a combination of physical postures, breathing exercises, relaxation and meditation to try and reach optimal physical and mental health. There are few studies in MS, but many anecdotes reinforce the view that deep relaxation and the strengthening of muscle control which can be achieved using yoga can be extremely beneficial for people with MS. Oken carried out a randomized controlled trial of weekly Iyengar yoga and exercise in 69 people with MS. Significant improvements were seen in measures of fatigue and quality of life in the yoga and exercise groups compared to the control but no effects on mood or cognitive dysfunction were reported[25].

Homoeopathy

Homoeopathy is a complementary medical system which uses preparations of substances whose effects when administered to healthy subjects correspond to the manifestations of the disorder in the individual. It was developed by Samuel Hahnemann (1755-1843) and is now practised throughout the world. Recent large-scale metaanalyses of randomised controlled clinical trials of homoeopathy[26,27] have confirmed activity over placebo in a wide range of conditions. There are five homoeopathic hospitals in the NHS in the UK and homoeopathy is very widely used by people with MS. There are no clinical trials of homoeopathy in MS in the literature although there are case reports of improvements in symptoms[28] and very wide clinical experience.

Case study, anecdote and clinical experience suggest that homoeopathy is extremely effective for some symptoms such as spasms, bladder problems and diplopia experienced by those with MS. Long term homoeopathic treatment does seem to help some symptoms, both physically and psychologically[29].

Hyperbaric oxygen therapy

Hyperbaric oxygen therapy (HBO) involves breathing oxygen through a mask in a pressurised chamber. Treatment regimens vary slightly but usually consist of an initial course of around 20 treatments, each lasting an hour, spread over one month. Follow up treatment is then needed at less frequent intervals. Those who practise this therapy report improvement both in bladder symptoms and fatigue.

Case reports of benefit following HBO therapy in people with MS, and positive effects of HBO in experimental allergic encephalitis (the animal model of MS) led to clinical investigations in people with MS.

A systematic review assessed the evidence from 14 controlled trials of HBO therapy in those with chronic MS[30]. Six of the trials identified were excluded from the review as they were of poor methodological quality according to pre-defined criteria. Of the eight remaining trials, one reported a positive result and seven reported negative results for HBO therapy. The authors of the review concluded that: 'We cannot recommend the use of hyperbaric oxygen in the treatment of MS.' However, it should be said that there are approximately 50 MS therapy centres around the UK where this therapy has long been available and it continues to prove popular with many people with MS.

St John's wort

This herb, Hypericum perforatum (St John's wort), has been shown to be effective in mild to moderate depression; depression occurs in around one quarter of people with MS. The evidence for beneficial effects of hypericum comes from 23 randomised controlled trials, involving 1757 outpatients, comparing hypericum extract with placebo or with conventional antidepressants in people with depression. It is important to note that these studies were not conducted on people with MS, but on those recruited by, for example, psychiatrists and obstetricians/ gynecologists. A meta-analysis of these trials showed that hypericum is significantly more effective than placebo for the treatment of mild to moderately severe depressive disorders, but that further studies comparing hypericum extracts with conventional antidepressants in welldefined groups of people are needed[31]. Hypericum may have an advantage over conventional antidepressants in terms of adverse reactions. It seems to have fewer short-term adverse effects than standard antidepressants, although data on long-term effects are lacking[32].

Conclusion

It is not an option for health professionals to ignore the fact that people with MS do use a wide range of therapies about which most such professionals know very little. Health professionals should enquire about use of CAM by their patients, find out about the therapies and so have the ability to appropriately encourage or discourage their use in any individual. Given the rather limited possibilities of conventional medications and techniques in MS therapeutics, the therapies described here do provide some hope of improving quality of life in a significant proportion of people with MS. It is therefore appropriate that those with expertise in more conventional therapies should become acquainted to some level with complementary and alternative therapies.

References

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Bibliography

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