More Than Medicine

More Than Medicine
by Judith Hortsman
Arthritis Today

Some rheumatologists are changing their approach. Using "integrative medicine," they treat the whole patient.

Lori-Ann Lau was only 25 when rheumatoid arthritis (RA) hit with a full-fledged flare. Within two years, she was in a wheelchair, unable to walk even to the bathroom and barely able to use her hands and wrists.

"My joints were swollen and crooked, and I couldn't do anything. The pain was intense and it was everywhere," she says.

The medicine her doctor recommended didn't seem to help. However, two years ago she found a rheumatologist, James McKoy, MD, of Honolulu, Hawaii, who used a very different approach. He combined conventional medicine with alternative therapies, a practice known as "integrative medicine."

This approach reflects a shift in philosophy among some medical professionals. It is a move away from the approach that focuses on the disease and prescription drugs to an approach that looks more at the individual who has the disease. Dr. McKoy is one of a small but growing number of rheumatologists who are integrating alternative therapies into Western medical practice to use what's most appropriate to treat the individual.

Along with conventional medical treatments, these doctors include a range of therapies that aren't generally considered "medicine," such as acupuncture, meditation, massage, herbal remedies and some dietary supplements. They are sending patients for yoga and tai chi. Some of them are praying with their patients.

But is this good medicine? Yes, say these doctors, especially for people with chronic ailments such as arthritis.

Treating people with arthritis is a long-term proposition that requires using every tool available. "This isn't about substituting herbs for prescription medications," cautions Sharon Kolasinski, MD, who practices in Philadelphia. "It's about treating all aspects of a person's illness and wellness."

Integrative medicine provides what every person with a chronic ailment yearns for: a feeling your doctor has a truly personal interest in you, not just your disease, says Dr. McKoy.

"We're obligated to practice conventionally accepted evidence-based medicine," says Dr. McKoy, "but at the same time, we are obligated to treat the whole person. And that involves getting to know what's going on in the heart and mind of the individual as well as the body Û and there's no contradiction in that."

To treat Lori-Ann Lau, Dr. McKoy first drained her knees and injected them with cortisone, and began disease-modifying drugs. But he also recommended a blend of other treat-ments that included vitamins, minerals, aromatherapy, breathing exercises, and omega-3 fish oil capsules with each meal. Two or three times a day, her aching joints were massaged with essential oils from ginger, lemon, nutmeg, black pepper and peppermint; and he prescribed self-help classes and guided visual imagery.

Lau describes her response as nothing less than miraculous. "I was out of my wheelchair that day," she says, and within a few months her pain and other symptoms were much improved. "I didn't know what a difference it would make in my life," says Lau, now 29. "I still have pain Û I know it's going to be there Û but I can go on. Dr. McKoy is my miracle worker."

Arthritis Today talked to Dr. McKoy and three other rheumatologists about how and why they came to include alternative therapies in their practices.

James McKoy, MD
Chief of Rheumatology at Kaiser Permanente, Honolulu
Medical degree: University of Iowa College of Medicine
Other: He is a member of the Arthritis Today Medical Advisory Board, and has an ethnically diverse patient base that includes many Asians and native Hawaiians familiar with complementary and alternative medicine.

Exploring alternatives with your doctor

Many people want their doctors' help in choosing and using alternatives, but are hesitant to ask. Here are some tips for helping you work with your doctor with alternative therapies.

Ô Ask about it. Don't assume your doctor will be negative about unconventional therapies: Many doctors expect patients to ask about these treatments if they are interested.

Ô Allow time for discussion. Doctor's visits are often brief, so if you want to discuss a change in treatment, be sure to ask for extra time when you make an appointment.

Ô Be prepared. If you want to discuss a specific therapy, do some research and bring the information with you. This is also a good way for you to find out more about the treatment.

Ô Listen carefully to your doctor's opinion. This is especially important if your doctor's opinion is negative. We tend to tune out people who don't agree with us. Ask for explanations. If your doctor disapproves, what's the reason? Is the therapy potentially harmful?

Ô Ask for a prescription or referral. If a doctor prescribes it, the therapy may be covered by your health insurance or offered through your HMO or it may be tax deductible.

Ô Keep a record of the effects of the therapy. Also make sure any alternative therapy is in your official medical record. This is especially important if you are taking supplements or herbs that are blood thinners, such as fish oil.

Ô Don't keep secrets. Always tell your doctor about over-the-counter drugs, supplements, herbs and vitamins, and special diets or exercises. All good relationships are based on trust and mutual respect. When you are not honest with your doctor, you are setting up a bad situation Ò and a potential medical emergency.

If your doctor refuses to discuss therapies you want to try, you might consider changing doctors. No one doctor will be a perfect match for every patient Ò just as you are not a good patient for every doctor.

Philosophy of Care
"The medicine that has worked best for me is changing the mind-set of patients and giving them hope for a better quality of life. Healing is working with more than the body, and illness is more than the disease. My philosophy is an integrative mind-body approach that addresses the mental, physical, emotional and spiritual aspects in the care of each individual patient. It's motivating patients to use their own physical and mental resources for health and healing."

How He Came to Alternative Practices
"Conventional medicine is great," says Dr. McKoy. "But in my personal experience there were some failures."

Both his parents and four brothers have died of either can-cer or heart disease despite modern medical care, one broth-er at age 24. "That spurred my personal quest for longevity and my interest in alternatives," says Dr. McKoy. " I wanted to beat those odds."

As a child growing up in the South, he had seen people gathering roots and herbs as medicines to improve health. His lifelong faith as a practicing Christian taught him about the healing power of spirituality, and teaching martial arts expanded his appreciation of what the human body and mind could accomplish.

Once a doctor, he began to research vitamins, foods, herbs and other treatments, for himself at first and then for others. Soon he became known in Hawaii for his openness to alternatives and patients began to seek him out.

Alternatives Recommended
Dr. McKoy prescribes many alternatives that he says have some scientific evidence and that don't conflict with good conventional medicine. These include some herbs, supplements such as glucosamine and chondroitin, fish and flaxseed oil, nutrition, massage and aromatherapy. He refers patients to practitioners for acupuncture, chiropractic, traditional Chinese medicine, Native Hawaiian medicine, tai chi, qi gong and yoga.

But when asked which make the most difference, he cites one-on-one attention from the health provider, a positive attitude and mind-body therapies such as guided imagery and meditation. When appropriate, he will offer to pray with a patient. These practices relieve stress, fear and depression that weigh down the immune system and increase pain, he says.

Sometimes it's a matter of a touch, or a personal question, or a willingness to be open to a patient's questions about alternatives. That personal attention means a lot to someone who is in pain, he says, and it is one of the reasons people are seeking alternative practitioners who give them more time than their medical doctors.

"Other physicians may think these are placebo, but who cares, as long as they work?" he says. "These empower peo-ple with arthritis, won't cost them lots of money, and we don't have to worry about side effects. I have patients who are doing fantastic with a combination of conventional med-ications and mind-body medicine."

To spread the word about this approach, about twice a month, Dr. McKoy offers free classes for his arthritis patients on subjects that range from specific therapies like supplements to how to take control of your life, how to avoid toxic friends and Û a personal favorite of his Û "I Have Arthritis But I'm Still Sexy."

"Just the rapport, love and showing patients that you really care about them as a person and not just their joints is healing," he says.

Scott J. Zashin, MD
Private practice in Dallas and Plano, Texas
Medical degree: Dartmouth Medical School
Other: He is listed in the book Best Doctors in America, and produces a patient newsletter.

Philosophy of Care
"I try to treat my patients the way I would want to be treated. I listen to my patients, and I like to solve their problems. Often, that takes a combination of conventional and alternative therapies. It takes time, so I elected to drop off most managed care plans so I am able to devote more time to patients and continue to greatly enjoy my practice."

How He Came to Alternative Practices
About six years ago, Dr. Zashin had an elderly patient with chronic abdominal discomfort and rheumatoid arthritis. He was always grumpy because of his pain. "One day, he came in smiling. He said acupuncture had eased his pain. I thought, 'Boy, if it can help this guy, I need to know about this,'" says Dr. Zashin.

Dr. Zashin learned how to do acupuncture and at about the same time became increasingly interested in the herbal and other alternative therapies patients were asking him about, especially those patients who weren't getting relief from conventional therapies.

"I could have said that there were no studies about these treatments and ignored their questions," Dr. Zashin says. "But I decided to look into what was known about the specific therapy, so I could provide them with the available information Û positive, negative or neutral Û to make an informed choice."

In most cases, it's the patient who brings up alternatives, but Dr. Zashin will suggest them when conventional therapies alone aren't enough. Some patients, like Pam McGee, 53, are a bit surprised to hear a physician recommend an alternative therapy. "But it was a pleasant surprise, because it really does work," says McGee, who is finding that acu-puncture eases her osteoarthritis (OA) and fibromyalgia pain.

Alternatives Recommended
Dr. Zashin says his patients have gotten good pain relief from a form of electroacupuncture that uses low frequency electrical stimulation to help release endorphins, the body's natural painkillers.

"I'm definitely interested in herbs, but give people warnings that they are not FDA-approved and may have drug interactions," he says.

Dr. Zashin sometimes suggests bromelain and boswellia for RA or OA; feverfew for migraines; and ginger for headache pain. He's prescribed DHEA for women with lupus (a prescription not over-the-counter version), and he says some patients with fibromyalgia have benefited from guaifenesin, an expectorant often used in cough syrups. But he says he cautions against some supplements, such as St. John's wort, because of side effects or potential drug interactions.

Therapies that Dr. Zashin thinks don't have much effect include homeopathy and magnets, "But if someone's doing something that doesn't do any harm and says they are getting some benefits, I don't discourage it. However, I don't recommend it."

Dr. Zashin recommends mind-body therapies, including meditation, and believes in the power of prayer and spirituality. "We have a weekly prayer session in our office where my staff will get together and pray for patients who we feel would particularly benefit from some extra thoughts," he says.

Justus Fiechtner, MD, MPH
Solo private practice in suburban East Lansing, Mich.
Head of Rheumatology, Michigan State University
College of Human and Osteopathic Medicine
Medical Degree: Boston University School of Medicine
Other: He was a member of the first Arthritis Foundation Complementary Therapies Subcommittee.

Philosophy of care
"I believe in the comprehensive approach, using conventional and alternative therapies and the power of positive thinking. There's no doubt that patients who take control of their treatment get better faster, so I emphasize patient education and empowerment. I have a patient-directed practice, designing treatment for the person."

How he came to alternative practices
"I've had a long time interest in exercise for arthritis," says Dr. Fiechtner, a sometime marathon runner. "That's why I moved to Michigan: For 10 years I had my office at a large athletic club where I could have my patients exercise, particularly [by doing] water exercise."

Dr. Fiechtner also serves on the faculty of a nearby osteopathic college, where he says he was exposed to a "more holistic" and hands on approach to medicine. A few years ago, he spent a week at the Arthritis Program at Canyon Ranch in Tucson, Ariz., and met Andrew Weil, MD, a leader in exploring alternative therapy. "It changed my philosophy about treatment," says Dr. Fiechtner. "I had always been open to new medicine and new approaches, and now I began looking more closely at nonconventional therapies."

The timing was appropriate, since many of Dr. Fiechtner's patients were asking about alternatives. "Almost all my patients are on some food additive such as vitamins," he says. "Some refuse to take conventional medications." While he recommends some, he has instead focused on the therapies that can get and keep people active, and has a roster of therapists for referrals in those areas.

Alternatives recommended
Exercise remains the No. 1 non-drug "therapy" for Dr. Fiechtner's arthritis patients, combined with prescription arthritis drugs and several different kinds of alternatives. He has an array of approaches aimed at getting the person with arthritis moving again Û or keeping them in motion.

"I suggest anything the patient is capable of doing," he says. Often, that includes water aerobics, yoga and tai chi, with instructors specially trained to help those with musculoskeletal problems. There's even a tai chi water class he recommends. He has a massage therapist in his office and refers patients for osteopathic manipulation.

He finds that some patients do very well with acupuncture to break the pain cycle, especially those with fibromyal-gia. Mind/body therapies help with pain: He refers people for guided imagery, visualization, meditation, hypnotherapy and deep relaxation, and he sometimes refers patients to a chronic pain clinic as well.

But Dr. Fiechtner remains conservative about supplements. "We just don't know enough," he says, and cautions patients about the lack of regulation and uniformity of products available in the U.S. He does recommend the "natural anti-inflammatories" of omega-3 fish and flaxseed oils for RA or any kind of inflammatory arthritis; and glucosamine and chondroitin for patients with OA.

The key, according to Dr. Fiechtner, is adding to Û not subtracting from Û conventional medication. "I suggest many alternative therapies, using a little of this and a little of that, designed for the individual patient," he says.

Sharon L. Kolasinski,MD
University-based rheumatology practice
Chief of Clinical Service, Division of Rheumatology
Hospital of the University of Pennsylvania
Medical degree: New York University School of Medicine
Other: She was named one of the "Best Doctors" for women by Philadelphia Magazine in 2000.

Philosophy of care
"Arthritis is so much more than what is going on in the joint Û it has to do with all aspects of a person's life, and some of those can't be helped with prescription drugs alone. I try to learn as much as I can about my patients, and the integrative approach very much goes along with that. I like developing long term relationships and dealing with quality of life issues. Working with my patients, I try to find the best therapies for them, conventional and alternative."

How she came to alternative practices
Dr. Kolasinski's interest in alternatives began with the environment. When she was a teenager, she was a founding member of the Nature Resources Defense Council. She spent time in the rain forest in Costa Rica, and wrote a thesis for her degree in biology on the substances plants use to interact with animals.

Later, as a rheumatologist, she saw the many ways in which arthritis affects a person's entire life, including day-to-day functioning and the frustrations of coping with pain. So in the 1990s, when Harvard University studies came out showing the widespread use of alternative medicine, "I took that very much to heart," she says. "I began asking patients if they were using alternatives Û and it turned out a lot of them were."

In partnership with her patients, Dr. Kolasinski began to look for evidence-based information about herbs and other alternatives.

Now many of her patients know she is open to alternatives and ask about them. If not, she asks them, and may suggest a specific therapy Û but not to all patients. "Sometimes they need permission to try something like acupuncture," she says. "Other patients would never consider acupuncture, so there's no point in recommending it."

Alternatives recommended
Although Dr. Kolasinski gave a review of herbal therapies at the American College of Rheumatology's 2000 Annual Scientific Meeting last November, she's cautious about prescribing them because of lack of FDA regulation and studies. She does recommend vitamin D (400-800 international units a day) and vitamin C (500 milligrams) for people with osteoarthritis. However, she frowns on huge "megadoses" of vitamins. "There's no clear evidence that's the way to go," she says.

Instead, Dr. Kolasinski may prescribe massage, acupuncture, meditation and stress reduction Û all therapies her patients can find in the rehabilitation program at the University of Pennsylvania in Philadelphia where she teaches. She also encourages counseling because it can help people make beneficial changes and give them a sense of control over their symptoms.

But mind-body therapies must be broached delicately, she says. "Some patients are definitely not open to meditation." For these people, she suggests biofeedback, in which sessions with electronic monitors "feed back" information that shows how the mind can affect the body.

Exercise, especially with a mind/body component, is high on her list. "I'm asking people to do more [exercise]," Dr. Kolasinski says, naming yoga (which she does herself), tai chi, swimming and water aerobics.

Alternatives the Experts Recommend

While every patient, situation and doctor is different, our experts all agree on some therapies. Here are the alternatives they generally recommend for arthritis patients.

Self-help courses Patient education and empowerment are tops with integrative doctors. They recommend self-help courses to virtually every arthritis patient. These courses, offered for minimal fees in many places by the Arthritis Foundation, provide information and support and teach coping skills to help take control of the disease.

Mind/body therapies These were second on the list, prescribed for pain, anxiety, depression and improving attitude. These practices involve focusing and quieting the mind and body, and include meditation, visualization, deep relaxation, deep breathing, hypnotherapy and the moving meditations. These techniques may be taught through stress reduction programs that are low cost or covered by insurance. Once learned, they cost nothing to practice and have no side effects.

Moving meditation Yoga, tai chi and qi gong get high marks for doing double duty. These ancient Easter practices exercise the body and the mind, and calm the spirit. They improve balance, mood and strength. They are low cost, but be sure to get a referral to a teacher who is trained to work with people with arthritis and related conditions.

Acupuncture This therapy originated from the ancient Chinese theory of balancing the flow of vital life energy, called qi. Specific points on the body are stimulated by inserting hair-fine needles, with pressure, or with mild electrical pulses. It's recommended for pain control, and paid for by some insurers and HMOs.

Massage While some regard this as just a "feel good" passive treatment, our experts say the many kinds of massage can help break the pain cycle and help you feel good enough to exercise. Be sure the therapist is qualified to work with your kind of arthritis.

Herbs and Dietary Supplements All rheumatologists urged caution in using supplements and varied greatly in what they recommend. Two they agreed on: glucosamine and/or chondroitin, which may relieve osteoarthritis pain and stiffness and possibly stop further cartilage loss; and omega-3 oil (such as in fish or flaxseed oil) to ease inflammation.

Exercise This "therapy" is free, has no side effects and is guaranteed to make you feel and look better, experts agree. But it's probably the hardest of all therapies for people with arthritis to maintain. The Arthritis Foundation offers classes and videos to help get you going. For more information contact your local Arthritis Foundation chapter.
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