Integrative Rheumatology (Weil Integrative Medicine Library)

375 Pages·2010·1.95 MB·English

by  Randy Horwitz M.D.

Integrative Rheumatology
Weil Integrative Medicine Library
Published and Forthcoming Volumes
series editor
andrew t. weil, md
Donald I. Abrams and Andrew T. Weil: Integrative Oncology
Timothy P. Culbert and Karen Olness: I ntegrative Pediatrics
Victoria Maizes and Tieraona Low Dog: I ntegrative Women’s Health
Randy Horwitz and Daniel Muller: Integrative Rheumatology
Daniel A. Monti and Bernard Beitman: Integrative Psychiatry
Stephen Devries and James Dalen: I ntegrative Cardiology
Integrative Rheumatology
edited by
Randy Horwitz, MD, PhD
Medical Director, Arizona Center for Integrative Medicine
Assistant Professor of Clinical Medicine
University of Arizona College of Medicine
Daniel Muller, MD, PhD
Associate Professor of Medicine
Section of Rheumatology
University of Wisconsin School of
Medicine and Public Health
1
2011
1
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Library of Congress Cataloging-in-Publication Data
Integrative rheumatology / edited by Randy Horwitz, Daniel Muller.
p. ; cm. — (Weil integrative medicine library)
Includes bibliographical references.
Summary: “In this volume in the series, the authors describe a rational and
evidence-based approach to the integrative therapy of rheumatologic, allergic,
and autoimmune disorders, integrating the principles of alternative and
complementary therapies into the principles and practice of conventional
medical therapy”—Provided by publisher.
ISBN 978-0-19-531121-1 (hardback : alk. paper) 1. Rheumatism—Alternative treatment.
2. Autoimmune diseases—Alternative treatment. 3. Allergy—Alternative treatment.
4. Rheumatology. I. Horwitz, Randy. II. Muller, Daniel, 1953- III. Series:
Weil integrative medicine library.
[DNLM: 1. Rheumatic Diseases—therapy. 2. Autoimmune Diseases—therapy.
3. Integrative Medicine. WE 544 I5805 2011]
RC927.I55 2011
616.7’23—dc22
2010007434
ISBN 978-0-19-531121-1
____________________________________________
1 3 5 7 9 8 6 4 2
Printed in the United States of America
on acid-free paper
PREFACE
“Integrative Medicine is healing-oriented medicine that takes account of the
whole person (body, mind, and spirit), including all aspects of lifestyle.
It emphasizes the therapeutic relationship and makes use of all appropriate
therapies, both conventional and alternative.”
T
he term i ntegrative medicine connotes a separate fi eld of medicine to
many patients and practitioners. Most associate integrative medicine
with complementary and alternative (CAM) approaches to disease
management. In reality, integrative medicine represents a unique approach to
patients and to patient care. Its practitioners are rooted in Western medicine,
yet utilize traditional and complementary healing techniques and modalities
in an eff ort to help the body to heal. Th e value of such an approach becomes
apparent when confronted with chronic conditions for which inadequate
therapy exists, or when the use of such therapy is associated with considerable
adverse consequences. Th us, the fi eld of Rheumatology is ideal for integrative
interventions.
Th is text is designed to introduce the reader to some integrative approaches
that may be clinically helpful in patients who are dealing with rheumatologic
disorders. Early chapters introduce these modalities and interventions, and
later chapters provide recommendations for specifi c rheumatologic condi-
tions. Some of these deserve a preview.
Dietary therapy is a cornerstone of the practice of integrative medicine.
Hippocrates is credited with stating that patients should “Let your food be your
v
vi PREFACE
medicine, and your medicine be your food.” No other medicine is taken with
such regularity (and gusto) in the Western world as food. Patients who might
normally miss aft ernoon doses of medications rarely forget to eat lunch. In
Chapter 2, Johnson describes the potential impact of various food choices
upon systemic infl ammation. Th ough we routinely classify foods as “proin-
fl ammatory” and “anti-infl ammatory,” it is truly the composite of the diet that
contributes to health and healing. Years of clinical experience have docu-
mented the impact of dietary choices upon clinical outcomes, whether study-
ing the Mediterranean diet in cardiology, or the gluten-free diet in patients
with celiac disease. Th e heterogeneity of clinical rheumatology conditions
(even in those with the same diagnosis) may preclude large-scale defi nitive
trials, yet dietary changes can be made with small numbers of patients in a
clinical practice, with surprisingly good results.
I n Chapter 3, Calder discusses the importance of omega-3 fatty acids in the
diet (and as supplements)—a concept that has been popularized recently in
the lay press, yet is based upon sound nutritional science. Th e choice of dietary
fatty acids can have a signifi cant impact upon both the de novo production of
infl ammatory mediators following a provocative trigger, and upon the host
immune response. Many of our pharmaceutical interventions for rheumato-
logical diseases are designed to block the formation or the eff ects of infl amma-
tory mediators deep in their biosynthetic pathway. Increased intake of omega-3
fatty acids provides less substrate for the initial formation of these mediators,
thus dampening the host infl ammatory response. Neutrophil membrane fatty
acid composition can be measurably altered in as little as 6 weeks. Daily serv-
ings of fatty fi sh, or fi sh oil, also produce a modest attenuation of host immune
function (e.g., cytokine production) with no side eff ects. Th e addition of
omega-3 fats to the diet is routinely used in our practice for all infl ammatory
conditions.
Exercise is also an important component of lifestyle management for the
patient with arthritis (as it is for anyone). It is important to stress to the patient
all of the benefi ts of a regular exercise program. Many patients with arthritis,
particularly osteoarthritis, are reluctant to exercise owing to the widely held
belief that such activity will hasten the deterioration of the aff ected joints. As
pointed out by Yocum (Chapter 4), the use of appropriate fi tness professionals
(athletic trainers and physical therapists) with skill in dealing with joint disor-
ders is crucial. Th ese professionals will be able to suggest an exercise program
that will reduce direct stress on the joints, while providing benefi t to the car-
diovascular system, muscles, and bones. Classes also provide the peer-group
motivation needed to develop lifelong habits. Finally, adequate pain relief
is essential prior to beginning any exercise regimen. In concert with dietary
PREFACE vii
recommendations, exercise off ers both physical and psychological benefi ts for
all rheumatology patients.
Integrative medicine is a comprehensive approach to patient care. Although
many modalities are employed, the use of botanicals and dietary supplements
are most frequently identifi ed with the practice. Many of our current pharma-
ceuticals have been isolated from botanicals, and herbal medicine relies upon
the fact that many of these herbs have been safely used for generations.
In addition, naturallyrmaceutical therapies or alternative modalities are
used. Many of the therapeutic trials described, especially those involving
glucosamine and chondroitin sulfate, provide some documentation as to the
relative safety of these compounds for chronic use. Empirical evidence from
clinical observations may warrant a trial of these agents.
Th e benefi ts of manual medicine (Chapter 7) in dealing with chronic pain
have withstood the test of time in our own clinic. Although they cannot repair
joint erosions or regrow cartilage, we fi nd that most patients benefi t from
gentle osteopathic manipulation, massage therapy, or other manual modali-
ties. We are fortunate to work with Dr. Harmon Myers, an osteopathic physi-
cian who has studied and taught the Counterstrain technique for several
decades, and who has provided outstanding results (and relief) for our patients.
Th e key in properly using manual medicine in your practice is to fi nd trusted
and experienced practitioners. We urge rheumatologists to experience the
manual therapies fi rsthand prior to referring patients.
Th e fi eld of M ind-Body Medicine (MBM) is gaining prominence in con-
ventional medical practices, and is central to the practice of integrative medi-
cine. As more studies are published, more information regarding the central
role of the mind in the course of chronic conditions is emerging. Th e develop-
ment of psychoneuroimmunology as a distinct discipline is evidence of the
strong links between the mind and immune function. Mind-body interven-
tions can be as simple as a breathing exercise, or as complex as a session of
hypnotherapy. Th e techniques can be taught easily and, unlike pharmaceuti-
cals or supplements, are quite aff ordable. In addition, they are safe to use, with
an enviable safety profi le. We urge all healthcare practitioners to consider
introducing such techniques to their patients with chronic conditions. MBM
modalities can greatly aff ect pain sensation and symptoms, but can also miti-
gate the immunological eff ects of infl ammation. In Chapter 8, Broderick
explores the variety of MBM interventions that have demonstrated effi cacy in
the care of the patient who is dealing with rheumatological disorders, and why
such recommendations should be an integral part of your patient care.
Th e vast majority of our patients with (and without) rheumatological con-
ditions report sleep disruptions—oft en severe in nature. Th is is particularly
viii PREFACE
problematic in patients with fi bromyalgia. We typically begin our evaluation
with a careful sleep history, then focus our initial eff orts upon the restoration
of adequate sleep quality. Th e botanicals and supplements described in Chapter
9 are useful as gentle hypnotics, but are always combined with “sleep hygiene”
interventions and mind-body relaxation techniques for maximal eff ect.
Th e text then explores various non-Western systems of medicine.
Acupuncture is one of the oldest systems of medicine still being practiced. As
a distinct system of medicine, as opposed to an adjunct therapy, it is diffi cult to
fi nd valid experimental trials comparing it to Western therapies. Further, many
published trials are fraught with methodological challenges. In our clinic, we
recommend traditional Chinese medicine (TCM) therapy to many patients
with rheumatologic conditions—especially (but not limited to) patients with
OA. In cases of severe OA, symptomatic control is central, and we have found
acupuncture to be very eff ective in this regard. Any modality that allows the
patient to decrease potentially harmful medications, while permitting more
activity with less pain, is benefi cial. While eff ectiveness is not guaranteed for
all patients, a trial of therapy with a TCM practitioner or medical acupunctur-
ist is always worthwhile. In patients who are unable to tolerate narcotic drugs
or NSAIDs, acupuncture provides an important therapeutic alternative. Th e
modality is very well tolerated, and uses an approach that has withstood the
test of time. In China, true integration and respect for traditional and Western
healing practices routinely occurs.
Energy Medicine, as described by Chiasson (Chapter 11), encompasses
many diverse forms of therapy—both hands-on and distance healing. Th is
modality is one of the more diffi cult ones to explain to a conventional health-
care practitioner. In most cases, the “energy” that is being manipulated is
impossible to objectively measure and track. In addition, there are few studies
to support its use. In our clinic, we see many patients who report benefi ts from
such therapy. Th is may be related to an unmeasurable energy that is trans-
ferred, or perhaps it is a result of the practitioner’s attention and the “laying on
of hands” from a caring individual with good intent. In either case, the modal-
ity is very safe, has the potential for easing pain and/or anxiety, and is worth
considering as adjunctive therapy.
Other approaches are important to learn about, as many patients will be
using these as complementary therapies. Th e Ayurvedic approach, used
by millions of individuals in India and elsewhere, has been popularized in
this country by well-known practitioners, such as Deepak Chopra, MD, and
many patients may ask about the suitability for such an approach in the
treatment of rheumatological conditions. Chapter 12 provides a rudimentary
explanation of the Ayurvedic system and provides guidelines for the rheuma-
tologist who wishes to introduce this approach to patients, or at least to be able
PREFACE ix
to answer questions regarding the Ayurvedic treatment of rheumatological
disease.
Homeopathy i s one of the oldest forms of medicine practiced in the United
States. Until recently, one of our allopathic medical schools bore the name of
the father of homeopathy, Samuel Hahnemann. Since the release of the Flexner
report in 1910, however, the practice has fallen out of favor among conven-
tional Western practitioners. Few practices of medicine elicit as much contro-
versy and vitriol as that of homeopathy. In Chapter 13, Bell, an allopathic and
homeopathic physician and researcher, presents many cogent arguments for
reconsidering the use of homeopathy in patients with rheumatological condi-
tions. An overwhelmingly positive safety profi le combined with a high degree
of patient satisfaction and clinical improvement, especially among patients
with hard-to-treat conditions (e.g., fi bromyalgia), makes this choice a viable
option for many patients.
Th e text closes by exploring the use of Integrative modalities in the care of
specifi c clinical conditions, including osteoarthritis (OA), rheumatoid arthri-
tis (RA), fi bromyalgia, and systemic lupus erythematosus (SLE). In addition,
we address the special concerns of the pediatric rheumatology patient. Th ese
chapters are authored by respected rheumatologists, and provide guidelines
and evidence for the incorporation of complementary therapies into the care
plans for patients dealing with these conditions. Th e amount of research per-
formed oft en relates to the prevalence of the condition. For example, existing
literature tells us that many patients with SLE are using complementary and
alternative treatments. Unfortunately, except for a few studies with DHEA,
there is little or no published research to support the use of these therapies. We
have to remember that there are 10-fold fewer patients with SLE compared to
those with rheumatoid arthritis, which is about 1% of the population. Th is
relative scarcity of patients makes studies more diffi cult to perform. Nonetheless,
we can use our rational as well as intuitive skills and apply a range of integra-
tive methods to SLE. Just as in rheumatoid arthritis, we do not want to forego
the lifesaving allopathic treatments. Yet, just as we use similar allopathic treat-
ments for both rheumatoid arthritis and SLE, we can use anti-infl ammatory
supplements, herbals, and mind-body techniques for patients with SLE.
Finally, of all demographic groups that suff er from rheumatological condi-
tions, none deserves more attention than the pediatric patient. Potentially life-
threatening therapies are used chronically, and for more years in the young
person with arthralgias and chronic pain. It behooves the pediatric rheuma-
tologist to investigate every and all potential therapeutic interventions in an
attempt to avoid the long-term complications commonly seen with the use of
conventional pharmacotherapy. Any intervention that will help control pain
and allow for a dose reduction in analgesic and immunosuppressive therapy