Stroke

Fall 2000
Volume 11, Number 2

 Next Article  

Several alternative therapy modalities can be used in rehabilitation and prevention of stroke. Herbal medicine, nutritional supplements, acupuncture, as well as body and mind techniques may be useful adjuncts to conventional therapy. Clinical efficacy of these complementary approaches must be further evaluated in prospective, randomized, and properly controlled studies. If convincing evidence emerges in favor of the effectiveness of alternative therapies in rehabilitation, these therapies will undoubtedly be incorporated into standard rehabilitation protocols.

Introduction. Alternative or complementary medicine is defined as a broad spectrum of health systems, modalities, and practices that differ from the theory and traditions of medical systems dominant in contemporary society.

Many approaches of alternative medicine have been practiced for centuries by healers and doctors in other countries and other cultures, but these have not been studied by Western biomedical researchers. While some alternative medicine modalities are delivered by licensed professionals, many are practiced predominantly by lay providers. Only recently have some physicians begun providing certain modalities of alternative medicine.

Another interesting aspect of alternative medicine is that it includes traditional medicine of China and India. Traditional medicine is based on a particular culture and is part and parcel of a specific medical system in a given region of the world. For example, traditional Chinese medicine includes acupuncture, physical medicine, and nutritional and botanical therapies. In contrast, the traditional medicine of India is known as ayurvedic medicine. Most of what is now considered “alternative medicine” actually represents an updated version of traditional medicine from both Eastern and Western cultures. These aspects of medicine fall into the broad category of alternative medicine simply because they lie outside of the dogma of the contemporary medicine of the Western world.

Alternative medicine can be grouped into 6 major categories:

• botanical medicine
• nutritional medicine
• energy medicine
• mind/body medicine
• pharmacological and biological agents
• physical and manual medicine

Dr. Eisenberg and his colleagues surveyed 1539 adults in 1991 and 2055 adults in a follow-up study in 1997.1, 2 They found a significant increase in use of alternative medicine by the American public. The probability of users visiting an alternative medicine practitioner increased from 36% in 1991 to 46% in 1997. In both surveys alternative therapies were used more frequently for back problems, anxiety, depression, allergies, arthritis, digestive problems, and headaches. The authors estimated that total out of pocket expenditures related to alternative therapies was $27 billion, which is comparable with projected 1997 out of pocket expenditures for all US physician services.

At the same time, Eisenberg and his colleagues found a 380% increase in the use of herbal remedies and 130% increase in high dose vitamin use. The survey also found that nearly 1 in 5 individuals taking prescription medications were concurrently taking herbs, high dose vitamins or both. Since many herbs and vitamin supplements may either increase or decrease the potency of prescription medications, these findings suggest that approximately 15 million adults may be at risk for potential adverse interactions involving prescription medication and herbs or high dose vitamin supplements. Knowing the skepticism of the American medical doctors toward unconventional therapy, only 40% of users disclose the use of alternative medicine to their physicians.

Several factors motivate patients to use alternative medicine. While traditionally the main reason for seeking alternative medicine has been assigned to consumer dissatisfaction with the limitation of conventional medicine, the 1997 survey1 found that 58% of users turned to alternative medicine at least in part, to “prevent future illness from occurring or to maintain health and vitality”. These data suggest that more people believe that disease is linked to nutritional, emotional, and lifestyle factors that can be ameliorated by preventive measures of alternative medicine.

Because many so-called alternative therapies have no evidence supporting their efficacy, the government, under the significant pressure from the American public, allocated public funds to evaluate the efficacy of the alternative medicine by the standards of Western biomedical sciences. The National Institutes of Health have created the National Center for Complementary and Alternative Medicine with a budget over $50 million. The Health Care Financing Administration (HCFA) is considering demonstration projects to evaluate coverage of certain treatments, prevention, and wellness programs. Private payors have begun to include certain aspects of alternative medicine in their benefit packages.

Clinical research in alternative medicine has been undertaken over the past decade, but its results have not come to the attention of the mainstream medical professionals. Herbal medicine is a standard medical practice in Germany, but remains a subject of controversy in the US. Within the US, advocacy for unconventional medicine varies by medical specialty. In general, rehabilitation medicine has tendency to use unique complementary therapies, not included in most other conventional medical approaches. Here are several alternative therapies that can be used in rehabilitation and prevention of stroke.

Herbal medicine. Ginkgo biloba. Ginkgo biloba is one of the most popular plant extracts. It is used in Europe to improve symptoms associated with a wide range of cognitive disorders. It has recently been approved in Germany for the treatment of dementia. Its mechanism of action is thought to be related to its anti-oxidant properties that involve the synergistic action of flavonoids, ginkgolides, bilobalide and the organic acids.3 Ginkgo flavanoids are efficient free radical scavengers. Ginkgolide constituents competitively inhibit platelet activating factor binding at the membrane receptor. These actions might be responsible for beneficial effects in circulatory diseases.4 Ginkgo leaf extract has been shown to increase cerebral blood flow and might improve cerebral metabolism.4 Serious adverse reactions, including spontaneous bilateral subdural hematoma (2 cases) and bleeding into the anterior chamber of the eye, have been reported in several patients.

A 52 week, randomized, double-blind, placebo-controlled, parallel group, multi- center study in severely demented patients with Alzheimer disease or multi-infarct dementia revealed that extract of Ginkgo biloba was safe and that it appeared capable of stabilizing or improving the cognitive performance and the social functioning of demented patients for 6 to 12 months.5

Recommended doses of Ginkgo biloba for dementia are 120 mg to 240 mg per day in divided 2 or 3 doses.4 The duration of treatment is advised to be at least 8 weeks and should be reviewed after 3 months.

Alfalfa. The alfalfa (Megicago Sativa) leaf contains saponins, which appear to decrease plasma cholesterol without changing HDL levels.4 There is insufficient information available about other uses of alfalfa. Consumption of the alfalfa seeds may reactivate latent SLE.4 Typical dosage of alfalfa is 5 grams to 10 grams per day or as a steeped strained tea 3 times a day.

Ginger. Ancient Greeks used Ginger as a digestive aid. The medicinal parts of Ginger are rhizome and root. Ginger can have hypoglycemic, hypo- or hypertensive and positive cardiac ionotropic effects. Other effects of ginger include inhibition of prostaglandins and platelets and lowering of cholesterol.4 In sensitive individuals ginger can cause dermatitis. Ginger overdose has been reported to cause CNS depression and cardiac arrhythmias. The typical dose is 0.25 gram to 1 gram of dried root 3 times a day or 1 cup of tea 3 times daily.

Turmeric. Turmeric has been mentioned for its medicinal value in reducing cholesterol.4 Insufficient information is available about its use for prevention of stroke or heart disease.

St. John’s wort. The main use of St. John’s wort is for depression. There are several mechanisms proposed to explain the antidepressant effects of St. John’s wort. It has slight MAO inhibiting effect and it may inhibit serotonin re-uptake.4 St. John’s wort is recommended in a dose of 300 mg 3 times daily.

A 1996 review of 23 clinical studies involving 1757 patients concluded that St. John’s wort is useful in cases of mild to moderate depression. Overall, the herb was found to be 2.5 times more effective than placebo and to produce fewer adverse effects than standard antidepressants. The FDA, however, warns that St. John’s wort interacts with other medications metabolized via the cytochrome P-450 pathway, including antiepileptic drugs.

Garlic. Garlic is generally used for stroke risk reduction as its bioactive compounds, allicin and diallyl disulfide, are thought to promote the scavenging of free radicals and have cholesterol lowering properties.

Nutritional medicine. In a recent study published in the Journal of the American Medical Association in 1999, Joshipura and colleagues 17 reported the influence of fruit and vegetable intake on risk of ischemic stroke in 38683 men and 75596 women. These individuals were followed for 8 to 14 years in the Health Professionals follow-up study (men) and the Nurses Health study (women). A total of 366 women and 204 men had ischemic stroke. However, individuals consuming over 5 servings of fruit and vegetables a day had significantly lower relative risk of stroke than those who consumed one serving a day. An increment of one serving per day of fruit or vegetables was associated with a 6% reduction in a relative risk of stroke.

Supplementation with Vitamin C and E provides an anti-oxidative influence, while Vitamin B-6 and folic acid may reduce plasma homocystein levels.7, 8 The Nurses’ Health Study has demonstrated a reduced risk of coronary heart disease among women with the highest quintile of folate and Vitamin B6 intake.7 At the same time, the meta-analysis of the effects of soy protein on serum lipids revealed its ability to significantly reduce serum concentrations of total cholesterol, LDL, and triglycerides.9

Mind/body medicine. Meditation and relaxation exercises have been documented to reduce hypertension and hypercholesterolemia.10 Therefore, therapies such as yoga and tai chi that include meditation and relaxation may be effective in stroke prevention.

Acupuncture. Acupuncture is a component of the ancient Chinese medicine that can be traced back at least 2500 years. Acupuncture represents a number of techniques designed to stimulate certain anatomical locations on the skin. In most cases this stimulation is achieved by using thin, solid, metallic needles manipulated either manually or by electrical current. In spite of considerable efforts to understand the anatomy and physiology of the “acupuncture points”, their characterization remains controversial and largely enigmatic.

In 1997 NIH convened a consensus development conference on acupuncture. The panel concluded that promising results have emerged for the efficacy of acupuncture in nausea and vomiting, and in post-operative dental pain.11 The consensus panel also stated that acupuncture might be useful as an alternative treatment for a number of other conditions, including stroke rehabilitation.

Despite the failure of some studies to observe any benefit of acupuncture in stroke rehabilitation,12 a number of publications have described significant improvement in functional outcome in stroke patients who were treated with acupuncture in addition to standard therapy.13, 14 In these studies, acupuncture was found to improve balance, mobility, postural control, and the activities of daily living (ADL). In the first study13, 78 stroke patients with severe hemipareses were randomized to either a standard rehabilitation or to a standard therapy plus acupuncture. The latter group performed significantly better on the Barthel index of ADL at 3, 6, and 12 months post-therapy. These patients have also shown improved mobility, balance, and walking. However, more studies are needed to confirm the role of acupuncture in stroke rehabilitation.

Hyperbaric Oxygen Treatment of Acute Ischemic Stroke. Hyperbaric oxygen (HBO) therapy has been reported to improve outcome of stroke in experimental studies.15 However, in humans the effectiveness of HBO has not been substantiated.16 HBO therapy is generally found to be safe, and a small double blind pilot study demonstrated a trend favoring this therapy.17 At present HBO is still considered to be experimental.

Conclusions. The acceptance of alternative therapies should be done cautiously and critically. There is evidence that some forms of alternative therapies may have value in stroke prevention and rehabilitation. More evidence is needed to determine the timing of these interventions, i.e., to define whether they are more effective in an acute or a later stage of rehabilitation. Unraveling the mechanism of action of the apparently effective alternative therapies will help them gain acceptance in prevention and treatment of stroke.

Address comments and questions to:

Elena Draznin, MD
701 E. Hampden Avenue, Suite 320
Englewood, CO 80113

 Next Article