Alternative Treament

Pulse Electromagnetic Field: PEMF electromagnetic mats, is it hocus pocus or is this a real life treatment

Virginia Thornley, M.D., Neurologist, Epileptologist

April 8, 2018

 

Introduction
Many patients suffer from chronic pain due to a number of medical conditions. Medications have been tried, physical therapy, ablative procedures, even nerve stimulators have been implanted without much luck. Treatment always has to start somewhere and just because a treatment modality sounds inconceivable does not mean it will not work. First, anecdotal and testimonial reports come in, followed by small case series, then large randomized clinical trials which are the gold standard studies. This is the final step before they are officially approved to be on the market with the nod from the FDA and eventually covered by insurance.
One may have seen a commercial about electromagnetic mats, or even seen someone bring one out to use. Or perhaps seen on street corners, vendors swearing by magnetic wristbands. Pregnant women have heard about electromagnetic wristbands to help with nausea but what is all the hoopla? Is it just a hocus pocus magic trick with effects due to a placebo reaction or is there really a science behind it?
Mechanism behind PEMF
One such treatment is the PEMF or the pulse magnetic field treatment. In the field of PEMF or pulsed electromagnetic field therapy, there is an extremely low electromagnetic field that depolarizes, repolarizes and hyperpolarizes the cells. The idea is that there is an inherent gravitational magnetic energy coming from the earth which exerts some effects on the human system and the way the human systems work. The idea is that cells are dependent on small amounts of energy in order to function. Physicians are well aware that sodium channels open to allow sodium to propagate causing an electric current within the nervous system. It is a similar concept, these electrical currents allow the systems to do their natural function. Cells are dependent on a certain amount of positivity or negativity for channels to open and close within the cell membrane. When this is disrupted the cell cannot efficiently perform its function.  It focuses primarily on the microvessels dependent on this energy where wastes are expended because the cell is metabolizing more effectively with increased blood flow at the microcirculatory level. The microcirculation is dilated rather than constricted and able to carry away the natural products of metabolism. In addition, microvessels are important in serving the purpose of transmitting products from one organ to another. When this does not occur, the system is at an imbalance which likely contributes towards the diseased state. This energy can be directed towards the area of interest to modulate pain or exert its desired results.  As far-fetched as it sounds what is more astounding are the many scientific reports showing the medical benefits of this concept.
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Some scientific studies corroborating its effectiveness while some could not come up with an effective conclusion nor a negative outcome

It has found its way in a myriad of conditions including pain, psychiatric disorders such as depression, neurological conditions making it a plausible alternative in treating medical conditions. In a randomized controlled clinical study evaluating pain from knee osteoarthritis in 57 patients, an electrodeless therapy delivered a sinusoidal magnetic field of about 4-12 hertz in the treated group. The treated group showed a great reduction in pain, stiffness, and disability compared to the control group with sham treatment. Using the VAS visual analog scale for pain and WOMAC (Western Ontario and McMaster University Index. Effectiveness was graded as very good and good in the PEMF treated group at 29% and 27% respectively compared to the sham-treated group at 0% and 15.5% (1).

In a pilot study of 24 patients, PEMF was applied showing a 50% reduction to neuropathic pain in a study in 2005 (2).

In one study of failed back surgery cases, PEMF was applied to 35 patients for 45 days. 67% of responders claimed meaningful improvement compared to sham-treated,  44% had less back pain 55% had less leg pain in those treated. There was a higher response 60% in those who had a discectomy compared to those without(3).

PEMF was applied to a large group of patients of 482 and compared to 448 non-PEMF patients. Those PEMF-treated had a significant reduction of pain (4).

One review of 14 randomized clinical trials could not come up with a general conclusion supporting its effectiveness due to different types of frequencies, different parameters, and different settings used.

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In conclusion

While there have been numerous reports spanning 3 decades on not just pain but other conditions as well such as edema and healing in the post-operative state in plastic surgery, effectiveness in bony diseases, insomnia, even depression, regarding its effectiveness, the jury is still out.  Large uniform clinical randomized trials are needed to officially approve of this alternative type of treatment for it to be widely accepted as is always the case.  As with acupuncture which was previously considered Eastern medicine and has now gained popularity in treating medical conditions, anything novel will be met with some amount of skepticism. However, for any cutting edge open-minded physician this may be a non-risky alternative treatment in treating different medical conditions, when a patient has already failed everything. Just like Neo on the Matrix one may just need to take the red pill to keep your mind open.

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Reference

  1. Wuschech, et al, “Effects of PEMF on patients with osteoarthritis:results of a prospective, placebo controlled double blind study,” Bioenergetics, 2015 Dec., 36(8):576-85
  2. Weintraub, et al, “Pulsed magnetic field therapy in refractory neuropathic pain secondary to peripheral neuropathy:electrodiagnostic parameters-pilot study,” Neurorehab. Neural Repair., 2004, Mar., 18 (1): 42-46
  3. Harper, et al, “An open-label pilot study of pulsed electromagnetic field therapy in the treatment of failed back surgery syndrome pain,” Int. Med Case Rev. J., 2014, Dec., 8:13-22
  4. Ryang, et al, “Effects of pulsed electromagnetic field on the knee osteoarthritis a systematic review,” Rheumatology, 2013, May, 52 (5) 815-824.
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medical marijuana

Cannabinoids: the other side of the coin, side effects, drug-drug interaction and possible problems of cannabidiol and tetrahydrocannabinol

Virginia Thornley, M.D., Board-Certified Neurologist, Epileptologist

@VThornleyMD

April 6, 2018

 

Introduction

Medical marijuana seems like the shining breakthrough drug the shining pill in armor, the magic pill that seems to cure everything. However, there are always two sides to every coin. One must still proceed with caution. The phytocannabinoids, cannabidiol, and tetrahydrocannabinol exert their effects through the endocannabinoid pathway, the CB1 receptor is most abundantly found in the nervous system. Cannabidiol which has no euphoria acts weakly with the CB1 receptor almost as a reverse agonist blocking the THC from exerting its effect offsetting potent side effects of tetrahydrocannabinol.

The medical benefits are overwhelmingly numerous including ameliorating seizures, spasms from multiple sclerosis, peripheral neuropathy in HIV patients, chronic debilitating pain, post-traumatic stress disorder symptoms and other associated diseases. Despite the stigma of using it, the delay in clinical trials and marked hesitation of the medical community, medical marijuana has landed and there is no going back. Yet even with its numerous health benefits, it is always prudent to take a step back and examine any flaws as with any other new kid on the block or any new agent that comes along even though it’s been around for thousands of years.

Is marijuana safe for medical use? The take on medical marijuana by the FDA

So far from the FDA official website, the FDA does not recognize medical marijuana coming from the botanical plant with any medical indication. The FDA does not recognize it to be safe or beneficial for any type of disease or condition. The FDA will facilitate any companies interested in bringing quality products including science-based research. The full take of the FDA on marijuana can be found here https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm#use

Long-term effects on the brain

Perusing the scientific literature, it is difficult to find any long-term damage to the brain. There was a report in a heavy marijuana user where there was damage to the corpus callosum, possibly worse with young users (1). This is a small study of 11 heavy marijuana users with 11 age-matched cohorts. Diffusion tensor imaging was used. Previous reports alluded towards poor cognition with heavy marijuana use. This study is aligned with that. It was suggested that there may be increased diffusibility within the white matter tracts of the corpus callosum. Young age is thought to make the corpus more susceptible to white matter damage. The only caveat is this is with heavy use and the substance found in recreational marijuana is going to be a different form compared to medical marijuana extracted from the marijuana plant used for medicinal purposes. It is not clear if this report would carry over to medical marijuana users where the preparation of the product is much different(1).

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Effect on schizophrenia spectrum diseases

In a large study of 171 patients, it was found that with heavy use of cannabis, the age of onset of schizophrenia spectrum disorders seems to occur earlier (6). This is one of the reasons why in some dispensaries, it is not sold to patients with a history of schizophrenia. There are some anecdotal reports of some patients having a paranoia with medical marijuana that is reversible once taken off.

Effect on the heart, reports of myocardial infarcts and ST elevations

While the literature suggests low toxicity and most side effects are related to cognition and gastrointestinal problems, there are several cannabis-associated myocardial infarcts in the literature. The dispensaries in the state of Florida use a previous history of a previous myocardial infarct as a contraindication in using medical marijuana. These were synthetic drugs used recreationally. There was one case report where a heavy user suffered from an ST elevation and subsequent myocardial infarct after becoming toxic to marijuana used recreationally.  In one study, synthetic cannabis was used, the myocardial happened to a young patient where an atheromatous plaque was excluded as the source. Etiology and mechanism are unclear why infarcts should occur. It is quite possible that because it works on the 5HT receptor for anxiety which can cause vasoconstriction, this may be one mechanism. Other studies are needed to elucidate the mechanism of action.

Drug-drug interactions

Because medical marijuana is used as an adjunctive agent for epilepsy, perhaps off-label since it has not been approved through FDA as an anti-epileptic agent yet, it was found that medical marijuana used in conjunction with Clobazam (Onfi) tended to elevate Onfi at higher levels.

In one small clinical study, in 13 patients, 9 had an increase of about 60 in the Clobazam level and by 300 in Norclobazam level. There was, however, a tremendous reduction of seizures by >50% but Onfi (Clobazam and Norclobazam levels) should be monitored (3) on a routine basis to avoid any untoward toxicity.

Other milder symptoms

In one large study on Lennox-Gastaut syndrome where cannabidiol was titrated to a 20mg/kg over a course of 14 weeks, mild to moderate symptoms were noted including pyrexia, sedation, dizziness, and diarrhea. However, the titration rate was very rapid and the patents who were 50kg were quickly at 1000mg within 14 weeks which does not usually happen in the real world. Medications are usually increased over a longer period of time in slower increments.

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In summary

While everybody is touting the horn of medical marijuana it is always prudent to stand back and ensure there are no possible risk factors for adverse side effects. The most serious and common seen in the literature appear to be related to schizophrenia spectrum disorders and cannabis associated myocardial infarct. The only caveat is that the literature is peppered with these reports, however, the quality of the recreational drugs are vastly different from medical marijuana which tends to be organic and all natural extracted from the plant in licensed medical dispensaries. The extraction of the medical components is vastly different from the smoked synthetic version of tetrahydrocannabinol. So, is difficult to know if these reports would actually corroborate with use in medical marijuana. The ones with side effects were heavy users of recreational smoked types of marijuana, it is unclear if it was synthetic or organic. As the popularity of medical marijuana progresses, more information will be available regarding the side effect profile.

References

  1. Arnone, et al, “Corpus callosum damage in heavy use: preliminary evidence from diffusion tensor tractography and tract-based spatial statistics,” Neuroimage, 2008, Jul., 1, 41 (3): 1067-74.  “J Addict Med. 2017 Sep/Oct;11(5):405-407. doi: 10.1097/ADM.0000000000000326.
  2. Volpon, et al, “Multiple cerebral infarcts in a young patient associated with marijuana use, ” Journ. Addic. Med, 2017, Sep./Oct., 11(5):405-407.
  3. Geffrey, Drug-drug interaction between clobazam and cannabidiol in children with refractory epilepsy,” Epilepsia, 2015, Aug., 58 (8):1246-1251.
  4. Stewart, et al, “Obstructive sleep apnea due to laryngospasm links ictal to postictal events in SUDEP cases and offers practical biomarkers for review of past cases and prevention of new ones,” Epilepsia, 2017, Jun., 58(6): e87-90
  5. https://www.fda.gov/NewsEvents/PublicHealthFocus/ucm421168.htm#use
  6. Shahzade, et al, “Patterns in adolescent cannabis use predict the onset and symptom structure of schizophrenia-spectrum disorder,” Schizophrenia Research, 2018, Feb., 2 pii S090-9964 doi:10. 1016/j. schres. 2018.01.008 (Epub ahead of print)
  7. Orsini, et al, “Prolonged cardiac arrest complicating massive ST-segment elevation myocardial infarct associated with myocardial consumption,” J. Community Hosp. Intern. Med. Perspect, 2016, Sep., 7. 6 (4):31695
  8. Thiele, et al, “Cannabidiol in patients with seizures from Lennox-Gastaut Syndrome (GWPCARE4): a randomized, double-blind placebo-controlled phase 3 trial,” Lancet, 2018, Jan., 390 (10125):1085-1096

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