Complementary and alternative medicine in neurology: hype, hope and hazards

Edzard Ernst

Trends in Neurosciences 2002, 25:644-645

More and more neurological patients use some form of complementary and alternative medicine. Contrary to what many sceptics believe, not all of these approaches are useless. Contrary to what many proponents think, not all treatments are harmless. Neurologists should know more about complementary and alternative medicine and should advise their patients responsibly.

Complementary and alternative medicine (CAM) is booming. It has been defined as '...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' [1], a definition now adopted by the Cochrane Collaboration (http://www.cochrane.org/). About half of the US general population uses one form of CAM or another and spends US$14 billion on it every year [2]. Neurologically relevant conditions like anxiety, depression and migraine are among the most common problems that bring patients to providers of CAM [2], and surveys show that many of neurological patients try CAM [3].

Hype

Neurologists tend to be puzzled, perhaps even irritated, by this new phenomenon and wonder why patients turn to CAM at a time when orthodox medicine is more successful than ever before in its history. The motives that drive patients to try CAM are complex and factors like philosophical congruence, the desire for control over illness, or dissatisfaction with orthodox healthcare play a role [4]. A contributing factor is the continuous media hype that surrounds CAM in most developed countries. In the UK, for instance, reporting on CAM in daily newspapers is both more frequent and more positive than coverage of orthodox medical issues [5]. A plethora of CAM books that recommend CAM for virtually every medical condition, including neurological diseases, are available for the lay public. We evaluated seven popular CAM books and listed the types of treatment that are recommended for conditions frequently treated by neurologists [6]. A stunning number of different CAM treatments were touted for the following conditions: anxiety (n = 54), chronic fatigue syndrome (n = 64), depression (n = 87), headache (n = 78) and insomnia (n = 74). Remarkably, there was almost a total lack of consensus between the authors of these seven books, and almost every type of CAM seemed to be recommended for every condition.

Hope

But not all CAM is necessarily hype. For several forms of CAM, there is also hope that they might help in some neurological conditions. A few brief examples must suffice to support this seemingly bold statement. A meta-analysis of four randomized controlled trials (RCTs) with a total of 424 patients suggested that Ginkgo biloba extract (120–240 mg daily) can significantly slow down the clinical deterioration of Alzheimer's disease patients [7]. The following CAM therapies for anxiety are supported by encouraging evidence from systematic reviews of RCTs: aromatherapy [8], autogenic training [9] and kava extracts [10] (see following discussion on kava). St John's wort has been repeatedly tested for mild to moderate depression; a review by the Cochrane Collaboration, including 27 RCTs and a total of 2291 patients, demonstrated greater efficacy than placebo [pooled rate ratio = 2.47, 95% confidence interval (CI) = 1.69–3.61] and equivalence with conventional antidepressants (pooled rate ratio = 1.01, 95% CI = 0.87–1.16) [11]. However, for major depression, St John's wort is probably not effective [12]. The herbal remedy valerian is often recommended for insomnia; its effectiveness is supported by a tentatively positive systematic review of nine RCTs with a total of 390 patients [13]. Acupuncture has been shown to be an effective treatment of migraine in a meta-analysis of 22 RCTs with a total of 1042 patients; the pooled responder rate for sham-controlled trials was 1.55 (95% CI = 1.04–2.33) [14]. The herbal remedy feverfew has produced generally encouraging results in migraine prevention; a systematic review of four RCTs with a total of 196 patients yielded a cautiously positive result [15].

Hazard

Although some CAM treatments offer hope for some neurological patients, CAM should not be (but often is) viewed as risk-free. The hazards of CAM are diverse [6] and, again, only brief examples can be provided. Herbal medicines can be associated with toxicity. For instance, kava extracts have recently been associated with liver damage which, in some cases, was severe, and included at least one fatality [16]. Other herbal remedies can interact with prescribed drugs: Ginkgo biloba, for example, possesses anti-platelet activity and has been associated with brain haemorrhage when taken concomitantly with other platelet inhibitors [17]. St John's wort powerfully interacts with a range of prescription drugs, potentially causing a variety of clinical problems [17]. Even seemingly harmless physical interventions are by no means free of risk. Chiropractic upper spinal manipulation has regularly been associated with cerebrovascular accidents, often with dramatic consequences, including death [18].

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