- So as I stated, I'm Dr. Spears.
I'm one of the newer additions to the
Movement Disorder and
Parkinson's Disease Team
at the university.
So I'm gonna talk to
you a little bit today,
I've been tasked with talking about
alternative therapies
in Parkinson's Disease.
What we're gonna do is we're gonna cover
a couple things.
First and foremost, we're
gonna talk a little bit
about, really, the overview of some terms,
so we're all really on the same page
with the language we're
using so we can have
this open conversation about it.
Next, we're gonna talk a little bit
about some of the pros and cons
and specifically, the safety of some
of these alternative therapies,
because they're not all perfectly safe.
I'm gonna talk a little
bit, and there's no
way I can talk about
every alternative therapy,
so we're gonna hit some of the high points
with the alternative
therapies, and do a little
bit of show-and-tell, as well,
because there's a lot of very interesting
alternative therapies out there.
And then lastly, and this
is really a big topic
in Parkinson's disease and in general,
is the role of medical marijuana.
And just given by the
number of people here,
you guys probably ran out
of the medical marijuana samples, or?
(audience laughs)
Yeah, yeah.
What kind of chocolates
are those on the table?
- [Woman] Is that part of show-and-tell?
- We'll see, we'll see.
One disclaimer I have,
especially when talking
about Parkinson's disease in general,
is that every patient
with Parkinson's disease is unique.
There may be very well similarities
between given patients,
but every patient is unique.
So that one patient on the internet
who responds excessively well to marijuana
with his dyskinesias,
that may very well not
be the next person.
Everybody's very different
in their responses
to medication and their needs overall.
And I found, really,
especially on this topic
of alternative therapies, that patients
are really the best educators.
You guys are the ones who bring all
these new frontier treatments,
these new frontier alternative therapies
to the providers.
And a lot of this, and what I know,
is really based off of the experiences
of the patients I've seen.
So too often, I know that a perspective
that many may have with
alternative therapies,
and probably tough to read this caption,
but it's really the doctor
saying to the patient,
"We've exhausted all
conventional measures.
"One last desperate option is to put you
"on an alternative medicine
"that has 96% success rate."
So I know that may very
well be a perspective
that a lot of folks have.
It's not what we intend to do, though,
and I'll try to talk a little bit
more about that.
But talking, or at least laying out
the definition of alternative therapies,
and plainly put, this is a diverse group
of medical therapies,
interventions, treatments,
practices, or products
that share in their common
exclusion from conventional
Western practices.
Really, things that are
alternate to what we do,
mainly with pills and other therapies.
I think that definition is tricky.
And even the word alternative therapies
is a tricky definition
because it really implies
that these therapies
are really in opposition
or to replace the therapies that we have
conventionally for Parkinson's disease.
Things like Sinemet, or thinks like
the medications we use
for mood and psychosis
in Parkinson's disease.
And I really prefer the term,
complimentary than alternative medicine.
Because these therapies, by all means,
most every one I'm talking about today,
can be used alongside and together
with our conventional therapies
for Parkinson's disease.
So I call them complimentary
alternative medicine therapies.
At large, this group of therapies,
complimentary, alternative,
or what have you,
really focus on individuality, they focus
on the individual.
And they also have this
emphasis on wholism,
which is really this
logic of not just treating
a disease symptom, OK?
Not just treating a symptom of the disease
but that that symptom of disease pertains
to the part and treating the whole.
And it's, I think,
something that's definitely
something I took from this definition
and I think we should all strive to treat.
Now the thing about alternative therapies
is that they're not routinely taught
in medical schools.
And so, I remember back, I think it's
probably been about 10 years now
since I went through
the earlier coursework
in medical school, and I
think there was one day.
One day out of the entire four years
where alternative
therapies were brought up.
And it wasn't just specific
to Parkinson's disease.
It wasn't specific to neurologic disease.
These were alternative therapies
across all of medicine.
And that's really about
the extent that we get
as MDs and Dos in our
medical school training.
The other thing is that
alternative therapies
can be costly because
they're not routinely,
they're not always reimbursed by insurers.
So this is something that, by all means,
can have an effect on
what we do in prescribing.
And then of course, have a negative effect
on pocketbooks sometimes.
And then this last thing I have here,
this last bullet of the three,
is meant to be a double negative.
In that alternative therapies
are not uncommonly utilized.
By this, I mean that alternative therapies
are pretty common.
And we know that in the US alone,
patients with Parkinson's disease
about almost 50%.
40% of folks with Parkinson's disease
have tried some form
of alternative therapy
for the treatment of the symptoms
of Parkinson's disease.
And in Eastern countries,
this number rises
to about three in four, 75% of folks
have tried some alternative therapy
for Parkinson's disease.
We divide these, and plainly, we try
to divide these into things
like natural products,
mind and body practices,
and then alternative systems practices,
which is a confusing term.
But alternative therapies is really
a blanket term for a lot
of different therapies,
not just the things we think about
with this class of herbal medicines
and nutritional supplements,
but we're talking thinks like homeopathy,
chiropractic manipulation, acupuncture,
naturopathy, massage, music therapy,
and exercise therapy.
And this is probably
not an exhaustive list
of what really in total, makes up
these therapies we call
alternative therapies.
So some general principles,
some general principles, pros and cons.
And this is what I'm
just gonna call the rub.
This is the rub, in my mind,
is that alternative therapies at large
are not always well researched.
And as physicians prescribing therapies
and prescribing medications, we like
to see research and evidence.
We like to see the science behind
the therapies we use.
These alternative therapies are not always
regulated by the government, namely,
the Food and Drug
Administration or the FDA.
And so this also plays into how we use
medications really, on a frequent basis.
And that we like to
know is this medication
gonna be effective, first and foremost?
Or is this treatment gonna be effective?
How often do we have to give it,
what dose do we have to give it,
and what kind of side effects
are we dealing with?
And all that evidence, we just don't have
a lot of it.
We don't have a lot of it towards many
of these alternative therapies.
In this caption here, just says that,
it really hits upon
again, that even though
a lot of these are natural substances,
these are things that are felt to be
in the environment.
If the good Lord put them on earth,
then they can't hurt me.
There are a lot of side
effects that can happen
from natural therapies,
and this is a cartoon
with a woman who has flowers growing out
of her hair after using
the natural eye drops.
So to tie into and really talk about more
specific therapies, I just wanted to put
up this slide.
This is from the National Center
for Complementary and Integrated Health,
which is part of NIH,
or the National Institute of Health.
And they polled really and did a survey
about what type of alternative therapies
are used and what are the most common.
Really, out there beyond anything else,
we know that natural products are
the most commonly used
alternative therapies
with many others trailing behind.
So when we talk about
these natural products,
what we're really talking about are things
that are vitamins, minerals, and tinctures
at large, and other
herbals to that regard.
The key points.
The key points of these,
and I'm not gonna talk
about too many specifically,
is that, again,
the US Food and Drug
Administration, the FDA,
does not strictly regulate
herbs and supplements.
They just don't have enough manpower,
they don't have that emphasis to do so.
And the other thing is, is that there's no
guarantee, necessarily,
the safety, strength,
or purity of many supplements.
There's just no good governing body.
We just don't know what really is in some
of the products that are on
the shelves of the store.
Which is a little bit disheartening,
which is you need to be cautious about.
We know that to date, there have been no
dietary supplements shown to halt, slow,
or alter Parkinson's disease.
None that have been shown to halt,
slow Parkinson's disease.
But it's not for lack of trying,
and not for lack of trying.
Because there have been
a fair number of trials,
some of them very good and very
well-conducted trials,
looking at things anywhere
from Vitamin E, or Coenzyme Q10, which is
a common one that's out there.
Creatine, ginseng,
ginkgo biloba, uric acid,
inosine, which is the
other name for uric acid,
and St. John's wort, and that's just
to name a few.
These are all trials that have been
largely negative, or haven't shown results
to be really beneficial for patients,
namely for patients with
Parkinson's disease.
There are many, and
because our trials can't
keep up, our trials can't keep up with all
the alternative therapies.
Trials take a long time, they cost a lot
of money to run.
We're never gonna be able to trial
every alternative therapy,
so there aren't trials for everything.
To name a few, know there aren't trials
for things like ginger,
which is in the news,
green tea polyphenols, or green tea,
and milk thistle.
And then, again,
capitalizing on this point
at the bottom is that
to date, we just don't
have any positive trials for
these alternative therapies.
But there are a couple
alternative therapy honorable mentions.
And some of these are really interesting,
and some of them do have some benefit
as opposed to some of the herbals
and other supplements.
One of which is really interesting
and it's this whole
body vibration therapy.
And there's an interesting backstory
on whole body vibration therapy,
which apparently developed out of,
this is old timing docs, we're talking
almost 200 years ago, where they noticed
that patients with the shaking palsy,
or Parkinson's disease, who came in on
a long journey, on a bumpy back road
via horse drawn carriage,
if it was a bumpy ride,
that patient looked
better for a short while
at the beginning of that visit.
And so that, over time,
and that interesting notation,
kind of really spurred this interest
in whole body vibration therapy,
which a number of trials
have gone on so far.
It looks like there's a little bit
of evidence for it.
And it's actually still
actively being trialed
for Parkinson's disease.
I don't encourage anybody to shake
their loved one, or start shaking.
(audience laughs)
There's a lot of bumpy
back roads and I think
even bumpy front roads
here in Michigan, I hear.
That may very well be enough.
The other thing that's out there,
and this actually has lot of evidence.
And I think it was
trialed really right down
the road at Cleveland
Clinic, is the Theracycle.
And the Theracycle comes
in, at least the last
time I looked, the series
are 100, 200, and 300.
And this is a very special stationary bike
which utilizes this principle called
force rate exercise, forced rate exercise.
And so patients will
get on the Theracycle,
people get on this Theracycle,
which really forces you to go about 30%.
That's the sweet spot.
30% faster than your voluntary rate,
so really getting your heart pumping,
really getting you moving.
Doing that for a period of time,
and they found that, at least temporarily
after you do this workout
on the Theracycle,
you can have improvement in a number
of motor symptoms.
The speed of movement,
the swing of movement,
or reducing stiffness, and even walking
a little bit better.
But so far, those results
have been temporary.
So unless you're going back and forth
to the Theracycle every couple hours,
right now, which I don't recommend,
that would be exhausting.
But by all means, we're starting to get
some alternative therapies
that have some improvement.
I think, and I checked,
it's hard to find Theracycles online.
You can find them, and new they go
for a lot of money.
These things are thousands of dollars.
I encourage patients to go to a yard sale
or a garage sale and
pick up a stationary bike
for 10 bucks.
It's a little bit easier
on the pocketbook,
as long as they really push themselves.
But the Theracycle, by all means,
is something that can be helpful.
The other alternative
therapy, and this kind
of goes into that, really that umbrella
of herbal supplements,
or natural substances,
is Mucuna pruriens.
And this is a derivative of a bean,
of a velvet bean, also dubbed at times,
the dopa bean or the dopamine bean,
it has a lot of different names to it
on the shelves.
And this is interesting
because Mucuna pruriens
actually does, it actually does have one
of the main components, one of the main
active components that we use in a lot
of our medications for
Parkinson's disease.
And that's replacing
dopamine, or in this case,
giving dopamine, in the form of L-DOPA,
which your brain utilizes
and can help slowness,
stiffness, and tremor.
Now the thing is about Mucuna pruriens,
is that these beans
contain just a little bit,
just a little bit of the L-DOPA
and they don't contain that other part.
For those familiar with Sinemet,
Sinemet's the one name for the medication
with two names, the carbidopa, levodopa.
The levodopa's essentially
the L-DOPA component.
That's the work horse in that medication.
The carbidopa component is important
and included with that medication
because it helps offset things
like stomach upset and nausea and vomiting
from the medication.
And it helps offset, or help decrease
your body breaking down the L-DOPA
before it gets to the brain
where it can be active.
And the Mucuna pruriens doesn't have
a robust component of carbidopa.
And so it's one of these things that
if you need to eat, if
you need to eat enough
of the Mucuna pruriens,
enough of the velvet bean
to get more substantial
benefit, a motor benefit
from it, you may very well run into
a little bit of GI upset.
Probably great in areas where you can't
have access or you don't have access
to medications like Sinemet or these other
medications we have for
Parkinson's disease.
And very well could have effect,
especially for mild symptoms
of Parkinson's disease.
But as the disease becomes more advanced
and the symptoms become
a little bit heavier,
I think Mucuna pruriens may be
a little bit limited.
But by all means,
is one that I don't necessarily,
I don't naysay.
So one, we've talked
about a couple of things.
We talked about the whole
body vibration therapy.
We talked about the Theracycle.
And then the Mucuna pruriens which are
all things that do have a little bit
of evidence to show that they can help,
at least somewhat.
One thing that doesn't
have a lot of evidence,
although it has also been
tried, is acupunture.
And so acupuncture, it
really is this therapy
based off of an imbalance
or flow in energy.
And you get poked with a lot of needles
which apparently don't hurt.
I've never had acupuncture, but it really
doesn't smart too much.
But it's been tested
for Parkinson's disease
and acupuncture is one of the things
that hasn't shown a lot of improvement.
But the thing that has probably shown
the most improvement, and we know this,
both immediate and long-term, is exercise.
Exercise.
And if I had, and down in Florida I had
a prescription pad, and I would write
exercise on the prescription pad
and hand it to the patient.
Here I don't have a prescription pad,
so I just have to point my finger a lot.
Exercise is the most effective,
it's the most effective, hands down,
alternative therapy we have
for Parkinson's disease.
And if I had a pill, if I could put this
in a pill, I would, by all means.
It's the most helpful.
And the thing about exercise is it doesn't
really matter exactly what you do.
You don't have to be a weight lifter,
you don't have to be a
champion in that regard.
You can do boxing, whether it be through
Rock Steady or otherwise,
you can do tai chi,
has been found effective.
And this is one that the female spouses
always giggle when I
say, but tango has also
been found to be effective.
So it's anything.
Any exercise, anything that gets
your body moving, anything that gets your
heart rate up.
Now for 30 minutes at a
time, greater than half
of the days of the week,
I usually say four days
of the week or more, is hands down,
the most effective
alternative therapy we have
for Parkinson's disease.
Both immediate and long-term.
I've had many patients
even stave off starting
medications for Parkinson's disease really
just by exercise.
So we're gonna change gears.
We're gonna change gears here and devote
the rest of my time to talking
about medical marijuana.
OK, medical marijuana.
The question about medical marijuana
is one that comes up to 95%, or just about
every Parkinson's disease specialist
hears the question,
"Doc, what about medical marijuana?"
And even though that
question's posed often,
we already know about one-third,
36% of patients with Parkinson's,
have tried medical marijuana or cannabis
at some point, at some
point in their disease.
Now I have to put a
disclaimer on here as well,
because right now, and
right now, the environment
is that marijuana's still
federally classified
as a Schedule I, Schedule I drug,
meaning that the federal government
doesn't identify that marijuana has
a medical property or medical component,
and identifies it really just as a drug
of abuse right now.
Which really is tricky
because that interferes
with our ability to test
it, and then at large,
safely prescribe it and for anybody
to safely carry it.
So as I'm talking about this,
I just wanted to give some credit to one
of the movement disorder fellows
at the University of
Florida, Dr. Jakoviac.
He's not here today, I don't think,
but he provided a lot of these slides
and he's a great doc if you have
a chance to see him when
you come to the clinic.
But marijuana itself,
and we're not talking
about CBD or anything like that yet,
marijuana we know, has
about 60 active compounds.
60 active compounds is a pretty crude drug
or alternative therapy,
as it is, just in itself.
At large, the things
that make up marijuana
are these two compounds.
THC, which is that psychoactive component,
provides that euphoria, that good feeling.
And then CBD, the cannabidiol.
Don't get a lot of euphoria from that one.
It can serve even as an antipsychotic,
to an extent.
It can break down anxiety a little bit.
And people also believe
it has anti-inflammatory,
and for one specific condition,
anti-seizure properties.
But marijuana, we're talking
about marijuana itself,
we're talking about both
of those compounds, THC, and CBD.
And marijuana, whether
smoked, whether vaporized,
whether ingested, whatever mechanism,
has a lot of side effects
associated with it,
or can have side effects
associated with it.
And these are real side effects.
I won't read them all out to you,
but the major ones are can alter your
sensory perception, it
can cause perceptual
distortions and even
hallucinations in some.
It impairs memory and attention.
It can make people hungry.
That one I think is very well known.
And it can really change your gross
and fine motor skills.
It doesn't necessarily, marijuana doesn't
necessarily make you, especially from
a Parkinson's disease standpoint,
be able to use your hands better,
be able to work with your hands better.
And then chronically, we
know that there can be
a dependence on marijuana,
medical marijuana,
or marijuana in itself.
And it can lead to cognitive impairments.
We're even starting to identify now
that it can even promote or essentially
cause dementia, pretty significant memory
impairments long-term.
In addition to lung disease if smoked,
and then also increase
of other mood disorders.
Now the thing about marijuana is
that cannabidiol component,
that CBD component,
we actually have.
We have receptors throughout the entirety
of our body for cannabidiol.
And we call these the CB1 and CB2.
And we have a lot of
these receptors actually,
in different parts of the brain.
Including these deeper
structures of the brain,
the basal ganglia, are pretty heavy target
for Parkinson's disease.
So there's something here,
there's something here.
And we know that we have these receptors,
specific cannabidiol
receptors in the brain.
And we think, we think
that CBD could potentially
modulate, we can modulate the role
of those structures, and may even,
it's been speculated, they'd serve as
a neuroprotective role.
So knowing that there's some science,
knowing that just some science behind it,
we ask neurologists, and
these are neurologists
who take care of patients
with Parkinson's disease,
"What do you think?
"What do you think, or what kind of role
"do you think CBD has
"or could have for patients?"
A lot of them kind of said the things
that we'd probably guess.
That it might improve,
it might improve things
like appetite, pain, nausea, anxiety.
And then everything takes a little drop.
Things like tremor, stiffness, dyskinesia,
those type of things, I think at large,
neurologists are a little hesitant,
or at least don't feel that it packs
as much of a punch for.
And there've been studies now,
and there've been studies even dating back
to 2004, been studies of CBD and medical
marijuana in Parkinson's disease.
Probably the one that
has the most evidence
behind it, is one where they tested
for the levodopa-induced dyskinesias.
There's extra movements that you can get
with Parkinson's disease when you're
at a high level of the
dopaminergic medications,
the dopamine medications.
And based off of that, at least based off
of that study and what we have so far,
what we say is that these cannaboid
agonists and antagonists, CBD oil,
CBD in any other form, whether it be
levodopa-induced dyskinesias or otherwise,
right now, we just don't think
that they have effect.
We haven't found that they have an effect
for those symptoms or otherwise.
And that really dates back to some
of these studies.
And why the American Academy of Neurology,
our big governing body, at least I think
this dates back to 2017
when they reviewed everything.
For Parkinson's disease right now,
we can say it's probably not effective
or probably ineffective.
But that doesn't mean
that we throw the baby
out with the bath water.
Because again, these medications,
especially CBD and the
formulations of CBD,
haven't really been effectively tested,
rigourously tested, and
all the different types
of CBD haven't been tested in patients
with movement disorders
like Parkinson's disease.
And so we have this article that came out
not too long ago, with
some very good researchers
and big names in the field
of movement disorders
and Parkinson's disease that said
there still might be a chance.
We still have to do the
research and science
to see if there is a role for CBD.
And the American Academy of Neurology
really backs this.
While they don't support
using or prescribing
medical marijuana for
neurological disorders
right now, The American
Academy of Neurology
and their lobbyists do think that it would
be very helpful if we
could get this medication
from a federal level snuck over into
a Schedule II or above,
so we can start testing
this a little more rigourously,
so they can really look at this.
And so it's definitely not a stamp
of no, never, it's more of a stamp
of no, right now.
We need more evidence.
And I think this evidence is gonna come
because at large, while
it's federally illegal,
and this could very well have changed
since I even picked up this slide.
A lot of the United States now,
state-wide, are green.
Meaning that at some capacity,
they have some sort of law or legalization
of whether it be medical marijuana,
or recreational marijuana.
So there aren't many
states left that don't
have some type of law or legalization
for marijuana, especially
for medical purposes.
Now in Michigan, in addition
to spelling marijuana
in a very interesting
way, just as of July 2018,
Parkinson's disease just now made the list
of conditions for which you can get
medical marijuana registration for.
And just as of July 2018.
And that joins a pretty big list now
of qualifying conditions.
So there's a lot of
things that you can have,
many things no one wants,
but a lot of symptoms
and diseases you can have that qualify
for medical marijuana in
the state of Michigan.
Now to access it,
because that's the next question.
One, I think movement disorder specialists
and neurologists at
large, we don't have a lot
of evidence that it's
effective for the symptoms
of Parkinson's disease, but it's legal
in the state of Michigan to prescribe it.
So how do I get it?
Let me try it.
Right now, there's an application process
where it's actually fairly simple,
and it's fairly simple going online
and going through the application process.
With just getting a couple things,
paying a small fee, and a fee as well
to the designated caregiver.
They're gonna be the ones primarily
to carry medical marijuana.
Because they'll need a registration
and a license to carry
it if they're giving
it to you or for you.
And then you do need
a physician certification form.
And this form is pretty
much a check mark box
and a signature from a physician saying
that you have such and such condition.
So this comes back to really this cartoon
of as physicians, are we exhausting all
the conventional measures and then just
leaving the alternative therapies,
which has success rate behind.
I think right now, as a physician,
especially one treating
Parkinson's disease,
which has lot of symptoms that can be very
challenging and tough to treat.
I hope, and I can speak
for most of our physicians
in the movement disorders division here
at Michigan, that we want more therapies.
We want more therapies,
especially those backed
by evidence, especially
those that are legal
and we're allowed to use
to treat the symptoms
of Parkinson's disease
so we can help our patients.
We just have to do so
in a safe and effective manner.
So in summary, right now, there are no
dietary supplements that are proven
to be effective in the treatment
of Parkinson's disease.
The Theracycle has proven
short-term benefits
in the motor symptoms
of Parkinson's disease.
And exercise, exercise has proven short
and long-term benefits
in Parkinson's disease
and is hands down the
best alternative therapy.
And marijuana, CBD and
THC, so marijuana itself,
has no proof of benefit
in Parkinson's disease
and carries risks for side effects.
However, that subcomponent, that CBD,
has distinct neurobiological properties
which really demand further study
for safety and efficacy so we can start
to utilize this, if it's effective.
So we can start to utilize this in a safe
and effective way.
We're just not there yet.
So these last couple slides
are really just animations.
And I know with Parkinson's disease,
really the phrase, grab
the bull by the horns,
depending on what type
of day you're having,
can really be one that's tough.
But whether it be with
conventional therapies
prescribed by your doctor, whether it be
for motor symptoms of Parkinson's disease,
or non-motor symptoms
of Parkinson's disease
like those in mood and psychosis.
Whether it be conventional or alternative
therapies, by all means, we want you
to really grab the bull by the horns
with this condition so
you can take it down.
So with that, I want to say thank you
and happy to answer any questions.
(audience claps)
