Complementary Therapies for Parkinson’s Disease

Complementary Therapies for Parkinson’s Disease

Complementary therapies are non-pharmacologic treatments that can complement and enhance modern medicine.  Complementary therapies include exercise, mindfulness, manipulation (acupuncture, massage), creative pursuits (socialization, hobbies), and herbal remedies.  They are most effective in treating stress, anxiety, stiffness, pain, insomnia, nausea, bloating, and memory.

On August 4 the American Parkinson Disease Association (APDA) monthly series, Dr. Gilbert Hosts focused on the topic of Complementary Therapies for Parkinson’s Disease.  During the pandemic, movement disorders specialist Britt Stone, MD, trained in integrative medicine, the practice of integrating traditional remedies and modern medicine in treatment of the whole person (mind, body, and soul).  She spoke for about 20-minutes about complementary therapies for Parkinson’s disease before answering questions for another 20-minutes.

The webinar can be viewed on the APDA YouTube channel.

The Stanford Parkinson’s Community Outreach Program has more information about Complementary Therapies for Parkinson’s Disease here.

And now, on with my notes.

– Denise

American Parkinson Disease Association

Dr. Gilbert Hosts:  Complementary Medicine and Parkinson’s Disease, August 4, 2021

Speaker: Britt Stone, MD, PhD

Dr. Stone’s mother suggested she pursue an integrative medicine as supplemental education to her MD.  The pandemic gave Dr. Stone the perfect opportunity to complete that.  It dovetails nicely with her western medicine training and has become something she feels passionately about.

Complementary Medicine – non-pharmacologic treatments that can complement and enhance traditional therapies

Examples of complementary medicine approaches used for PD

  • Exercise / movement – can slow progression of Parkinson’s symptoms
    • Choose something you enjoy enough to exercise several days per week
    • Some have been studied and shown to benefit those with Parkinson’s
      • Boxing
        • Rock Steady Boxing
        • Independent instructors / trainers
      • Dance
        • Waltz, Tango, Two step, Line Dancing
      • Yoga
      • Pilates / Alexander technique
      • Tai chi and Qigong
    • Benefits include
      • Movement
      • Stretching
      • Cardio
      • Social engagement
      • Cognitive strengths
  • Mindfulness techniques
    • Meditation (formal practice)
    • Informal
      • Prayer
      • Enjoy nature (stream, sunset, birdsong, ocean, etc.)
      • Quiet contemplation
      • Destress
        • Lower blood pressure
        • Deep breathing
  • Manual practices
    • Acupuncture / acupressure
      • Fatigue
      • Constipation
      • Allergies
      • Insomnia
      • Chronic pain
      • Anxiety / depression
    • Massage
      • Muscle tightness / spasm
      • Chronic pain
      • Therapeutic touch relieves stress
  • Creative pursuits
    • Social interaction
    • Sense of play
      • Singing / choir
      • Music therapy
      • Dance
      • Theater
      • Art therapy

Integrative Medicine – a clinical approach that focuses on treating the whole person (mind, body and soul) with evidence-based practices, using complementary therapies in combination with standard therapies

Evidence-based practices – the integration into clinical care of medical practices that are supported by clinical trial data (research).  

It seems silly to have to prove intuitive things that seem true through randomized, controlled trials, like the fact that movement is good for people with Parkinson’s.  These studies can be further confounded by study participants having ailment of aging, like arthritis, back issues, or vertigo, in addition to Parkinson’s.  Yet, this is how medical science is done.  

Herbal medicine for PD

Mucuna Pruriens (velvet bean)

  • Naturally occurring source of levodopa
    • Contains 6-9% levodopa by weight
  • Can be purchased at health food stores
  • No standardization of Mucuna pruriens products to ensure that a single bean or pod of beans contains a reliable and consistent amount of levodopa
    • This is why pharmaceutical sources of levodopa (Sinemet) is preferred
    • Each Sinemet pill has a precise quantity of levodopa
      • More predictable
      • Easier to use
  • Dr. Stone has had patients in early stages of PD who have not been prescribed Sinemet and are interested in whether Mucuna pruriens will be of benefit with mixed responses
    • No noticed any effect
    • Noticed some effect (could be placebo)

Examples of herbal treatments for PD symptoms

Plants known to be beneficial for these symptoms based on experience or research.  As far as is known, these plants are not harmful, do not interact with Parkinson’s medications, and are available at the grocery or herbal / health food store as dietary supplements and/or teas.

  • Sleep, particularly when insomnia is due to anxiety, nervousness, or a ‘racing’ mind
    • Chamomile (or Sleepy Time) tea – 2 controlled studies show it is calming
      • Rare adverse reactions, excepting in those allergic to chamomile
    • Passionflower – shown more effective than parsley for anxiety over sleeplessness
    • Valerian root – and muscle spasm
    • Skull cap – and muscle spasm
  • Memory
    • Rosemary – shown to help with short term memory recall in exams
      • Roman students inhaled rosemary prior to studying for exams
      • Ophelia quotes about rosemary for remembrance in Hamlet
    • Lion’s mane (mushroom looks like a brain) – shown to enhance neurogenesis
      • Good replacement in recipes for those with shellfish allergy
  • Mood
    • Lavender – calming aromatherapy (candles, soap, potpourri, sachets, etc.)
    • Lemon balm
    • Blue Vervain / Verbena 
  • Muscle spasms
    • Arnica – natural pain reliever, available at the drug store
    • Juniper – anti-inflammatory for muscle spasm and pain of arthritis
      • called cedar in TX
    • Valerian root – and sleep
    • Skull cap – and sleep
  • Nausea / bloating
    • Ginger – digestion and nausea
    • Any herbs and spices that season food, jumpstart the digestive system to work effectively
      • Garlic
      • Sage
      • Cayenne pepper
      • Nutmeg 
      • Rosemary
      • Peppermint

Many plants work in synergy with your body to help it function properly.  Start small by increasing the percentage of your diet derived from plants.  Especially for those that have beneficial properties.  If you do feel better, you may notice more effect from adding plants with beneficial properties in the form of supplements (pills), tinctures, or teas.

Medical marijuana for PD

A brief history – In the 1960s there was a lot of research done on psychedelic drugs, including magical mushrooms, hallucinogens, and marijuana.  In reaction, there was a war on drugs that quashed a lot of the clinical research into these substances particularly in the fields of psychology and neurology.  We are only now able to continue that research and learn if any of these drugs are beneficial for patients.

Remember, there is not going to be one thing that is the treatment or cure-all for everything.  Nor is one treatment going to work for everyone.  Everyone has different comorbidities, different reactions to medicines, and there are different formulations for how treatments are prescribed.

  • Cannabis is a genus of plant that contains hundreds of different chemicals.
  • Medical marijuana consists of 2 purified chemicals from cannabis: THC and CBD
    • THC is psychoactive
    • CBD is anti-spasm, anti-anxiety
  • One could hypothesize that medical marijuana may help tremor, dyskinesia, stiffness, insomnia, dystonia, pain, or weight loss associated with PD.
  • Only limited clinical trials of medical marijuana on PD symptoms have been concluded
    • Due to marijuana’s confused legal status across the US, including 6 classifications:
      • CBD Only
      • Decriminalized
      • Medical Only
      • Medical and Decriminalized
      • Legalized
      • Fully Legal
    • Marijuana is still classified as a Schedule I Controlled Substance on the federal level.  This affects federal research grant funding.
    • Because of this we don’t know how cannabis benefits PD symptoms
  • The Parkinson’s community is advocating to ease federal restrictions on medical marijuana research
  • Medical marijuana is a medication and can have side effects, including:
    • psychosis
    • sleepiness
    • confusion
    • difficulty concentrating
    • apathy
    • mood changes
    • gait imbalance / increased fall risk
  • Dr. Stone has seen the most benefit in her patients with:
    • muscle spasm
    • sleep
    • appetite
    • nausea
    • anxiety (can decrease or increase!)

You should ALWAYS discuss with your doctor before integrating any of these therapies into your treatment plan.  DO NOT try everything all at once.  In order to determine if a complementary therapy is of benefit to you, you must be able to distinguish its effect from that of other aspects of your lifestyle.  

Therefore, you should incorporate one complementary therapy at a time.  Determine the right dose, method of admission, timing, etc. for you.  Decide if you want to continue using it, then move on to try another complementary therapy.

Questions & Answers

Q. Any chance of getting the complementary therapies you discussed paid for by insurance?

A. This question was submitted in advance of the webinar so Dr. Stone had time to do a little research.  Some insurances will cover massage.  If you have a flex spending account, you can buy nutritional supplements, exercise equipment, massage therapy with that, especially if you have a doctor’s prescription.  If you have private insurance, ask them if they will cover acupuncture, etc.

Q. In general, neurologists may be wary of herbal medicine and may not want to discuss it with patients.  Are there particular ways to find a neurologist who is more amenable to complementary medicine than others? 

A. There is an academy of integrative medicine.  They may have a directory of member physicians.  
Don’t assume your neurologist is closed-minded about complementary medicine.  Ask him/her how she feels about the complementary therapy you want to try.  Your inquiry may even break your physician out of their silo.
Referrals from fellow support group members are always a good.  That is one of the benefits of joining a support group!

Larger clinics may have an integrative medicine department, massage or acupuncture therapists.

Q. Are all these therapies demonstrated benefits against placebo in clinical trials? 

A. First, placebo is not a bad word.  How great is it that our mind can make us feel better without having to actually take a drug?  In accordance with the words of the Hippocratic oath, “first, do no harm,” I would much rather be able to give you something that has no possibility of adverse effects.  That’s a win-win!

Chamomile, rosemary, and ginger have all been tried against placebo and been more effective.
Exercise and other nonpharmacological modalities (massage, acupuncture, stretching, etc.) are known to be better than placebo and give you a sense of wellbeing that make you feel better.  Because we are complex beings, we can never separate out that sense of wellbeing and hopefulness from the effects of taking a drug.  

You can go for a surgery and believe it will go horribly.  The surgery can go just fine, and you still feel horribly.  There are things at play there that are beyond our understanding.  It is important to tap into positivity and hope that things are going to go better.

Q. Is there evidence based clinical studies on the befits of moderate vs. intense exercise on a daily basis?

A. The key is that you need at least 30 minutes of rigorous exercise (getting your heart rate up) to get the extra benefit.  Perfection is the enemy of good.  You don’t want to say that if moderate isn’t as good as intense, I’m not going to do anything at all.  

The goal is to increase your personal effort over time.  Because what is moderate for one person is intense for another person.  It depends on where you’re starting to exercise.  Start with exercise that is doable and meaningful for you.  Set goals so you can increase your effort as tolerated.

Q. What about weight training for maintaining strength?  How does that fit into our exercise goals?

A. Dr. Stone has not issue with weight training.  It is good to build muscle and endurance.  But the idea of a doing a good cardiovascular workout is very important.  You don’t want to weight train as the expense of cardio exercise.
For some people, depending on their symptoms, it can be riskier.  You don’t want to hurt yourself either by overdoing it or having bad form.  Dr. Stone recommends having a trainer to help navigate weight training safely.

Q. Which complementary therapy should I try first?

A. It’s an ongoing conversation with your physician.  It depends on what symptoms are bothering you.  Some people have issues with constipation and nausea, others don’t have any of that, but they are sore and tight all the time.  
For the first person I would encourage ginger, suggest herbals that help the GI tract function well and discuss their diet to make sure they are well hydrated and are eating enough fruits and veg for fiber.  For the second person I might ask if they’ve considered massage, stretching, or acupressure.  

Everyone should be exercising!  Beyond that, you don’t want to get overwhelmed by adding a bunch of self-care tasks.  Just add one thing at a time and see if you find it beneficial.  Try one massage.  If it makes you feel better, try a monthly massage.  If you have an issue with sleep, try adding chamomile tea at bedtime.  If that works, you’re good.  Other people will have to try something more to improve their sleep.

Q. Someone interested in Mucuna pruriens is also on Sinemet.  Are there ways to take both?

A. Dr. Stone had a patient who did this.  Interestingly, she was very sensitive to medicines and had nausea when she added Mucuna to Sinemet.  Beyond the nausea she didn’t notice much of a difference when using the two together.  

Since they are essentially the same thing, sticking to one or the other and not jumping from one to the other is recommended.  Although Dr. Gilbert had one patient with a daily schedule of switching between Sinemet and Mucuna.  Perhaps the benefit she perceived was placebo.  As long as she didn’t experience adverse effects, Dr. Gilbert was fine with it.

Q. Are there any complementary therapies that have undergone study specific to Parkinson’s disease, especially meditation and relaxation techniques?

A. Yes, particularly prayer, contemplation, and quiet has been found to improve mood (depression and anxiety) in those with Parkinson’s.  

Q. A listener says exercise does not help them at all.  They do dance but feel fatigued.  Any thoughts?

A. Exercise is a big category.  What are you doing?  When are you doing it?  Are you doing it alone or with others?  Try to optimize your circumstances to get the most benefit with the least fatigue. 

Parkinson’s cause fatigue but other conditions can make fatigue more of an issue, so you should consult with your physician to rule those conditions out.

I tell people when you begin exercising you are deconditioned.  You’re going to be tired after exercise until you get adjusted to the routine.  Then, there are just days when you’re tired and you exercise because you should.  Exercise is like eating your vegetables or drinking water.  You don’t feel the immediate reward, but you do it because you know it is good for your body and you would feel even worse without it. 

Q. When trying a new alternative therapy and it doesn’t seem to be working.  How long should you try it for?

A. Give everything a couple months – unless it is horrible for you.  You can’t know if a therapy is really working for you in just a couple weeks.

Q. A listener researched and put her husband on Berberine, Lions Mane, Mucuna, and Cat’s Claw.  Can you recommend dosage for each?

A. Dr. Stone will not recommend dosages because everyone is individual and needs to discuss alternative therapies with their practitioner.  Dr. Gilbert asked Dr. Stone to comment generally on people who have found herbal remedies on their own with such a list.  How would Dr. Stone approach the situation.

Dr. Stone asks how long they’ve been using all those herbs together.  If it is working for them, she leaves the situation well enough alone. 

However, if they say they’ve just started, she advises people to start low and slow.  That means adding one thing at a time so you can tell which is beneficial, what’s not, what’s causing an adverse reaction, etc.  

Also, supplements are not created equal.  There is no overseeing body for manufacturing, ingredients, dosing, etc.  
Dr. Stone would ask what the person is trying to make better by using all these supplements and help them develop a plan to address those issues in a step-wise fashion so you can tell if the treatment is working or causing more problems.

Q. How does one find an herbal expert for consultation in your area?

A. The American Herbalist Guild has a list by state of herbal medicine schools.  You can contact those in your area and ask who has received certification, which requires 200 hours of training.  There is no license to be an herbalist in the US but this is accreditation. 

Q. Have there been studies to show the benefit of journaling, gratitude, or cognitive behavior therapy (CBT) for people with PD?

A. Dr. Stone didn’t investigate the research into these practices for this talk.  She is sure there have been studies specific to Parkinson’s disease, particularly for CBD.

Intuitively, journaling and practicing gratitude falls under the category of mindfulness and would be beneficial.  I just don’t know the actual data, but I will add these categories to my future talks on this subject.

Q. Should one be concerned with expiration of herbs?  Do any become toxic if they are too old?

A. If anything, when an herb becomes too old it ceases to be effective.  
Some herbs are better when used fresh as a tincture or tea as soon as picked.  Others can be used fresh or dried.  Still others are only used dried.  How it’s used depends on whether the plant is a leaf, berry, root, etc.

Q. What herbs are good for fatigue, weight loss, and balance?

A. Dr. Stone has not seen any herbs beneficial for balance.  There’s no pill, supplement, or shortcut to improve balance.  The only way to maintain or improve balance is to move.  Even still, with the progression of PD, postural instability is something that happens, and you just need to learn how to live with those changes.

Dr. Stone doesn’t know any herbs specifically for weight loss.  There are herbs to curb weight loss or to reduce water retention but Dr. Stone didn’t say what they are.

Dr. Stone would ask what the fatigue is coming from.  Ginseng can help pep people up if they feel they are dragging.  Otherwise, if your fatigue is from another reason, like anemia or thyroid issue, low vitamin B or testosterone, those conditions need to be treated to resolve the fatigue.

If the fatigue is a symptom of PD there is no specific medicine or herb to treat that.  Dr. Stone would discuss with her patients how to manage that with lifestyle adjustments.

Q. Have you ever encountered a patient who was only on herbal medicines and didn’t need standard PD medicines?

A. No.  Dr. Stone has had patients who wanted to be only on herbal medicines.  When she saw them, they looked very under medicated.  It hurt her heart.  Dr. Stone’s role is to help guide people through the management of their PD symptoms, not to beat them over the head with standard or alternative treatments.  

She has had patients who were adamant about not starting pharmaceuticals for PD.  They only exercised and changed their diet.  They insist they are fine, but you can see they are very stiff and very rigid, sometimes shaking uncontrollably and falling.  She does not encourage that.

For patients with minimal symptoms but wanted to employ exercise, complementary therapies, and herbals for non-motor symptoms, Dr. Stone is on board with that.  They’re not trying to treat physical symptoms with non-pharmacological therapies alone.

Dr. Gilbert has had similar experiences with patients.