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Volume III Fall 2001
A Message from the Chairman of the
Department of Rheumatology and Medicine
By, Dr. Steven Abramson
Osteoporosis Treatment at a Glance
By, Gary Zagon, MD
Pulsating Magnetic Therapy For Treating
Soft Tissue Rheumatism
By, Michael J. Colin, M.D.
The Diagnosis and Treatment of Temporomandibular
Joint Disorders and Xerostomia
By, Omar F. Suarez. B.S.,D.M.D.,F.I.C.C.M.O.,F.A.G.D.
"Really? Children get arthritis?"
By, Kathleen Haines, M.D.
A Message from the Chairman of the Department of Rheumatology and Medicine:In this edition of NewsRheum, we have chosen to highlight some topics in arthritis treatment that are usually overlooked. People think of arthritis as a disease of the elderly and are often quite surprised to learn that young individuals, including children, get arthritis too. Another condition that people do not readily associate with arthritis is temporal mandibular joint dysfunction. In yet another overlooked area, most patients who seek complementary medicine such as Yoga, acupuncture, herbal remedies and meditation, are perhaps somewhat shy about discussing it with their medical doctor. In fact, a recent study has shown that many patients may expose themselves to dangerous drug and herb interactions because they are embarrassed to report to their doctors the different herbal remedies they are trying.
Whether it is traditional treatments, experimental, or complementary medicine, we are proud that our physicians are actively involved in pursuing the most effective combination of therapies available. Our physicians and researchers can help our patients evaluate different choices and methodologies to manage their disease and symptoms. It brings me great pleasure to announce that our efforts to provide the highest quality of care for our patients will be supported by a philanthropic gift from the Schwartz Family Fund that will serve as seed money for several innovative grant proposals in alternative medicine therapies for arthritis. Our vision is to impose the same rigorous and scientific research standards that are used for traditional drug development, and apply them toward studying the efficacy of various alternative treatments and cures. We will be proposing grants to explore the relationship of meditation, acupuncture, biofeedback, targeted herbal remedies, and Yoga on symptom reduction in different arthritic and autoimmune diseases. We are actively exploring federal as well as private funding sources to help us pursue these goals.
In future editions, I hope to bring the readers further updates about this work in progress, along with our continuing genomic and biomolecular research. Osteoporosis Treatment at a GlanceOver the past ten years, osteoporosis, the condition of low bone density, has become increasingly recognized as a major cause of pain, deformity, disability and even death in the elderly. Especially with advances in other fields of medicine increasing longevity, the consequences of osteoporosis have gained new prominence. Fortunately, as our understanding of this condition has advanced, so has our ability to treat it.
As with any other medical disorder, the key to treatment starts with physician and patient awareness, recognition and diagnosis. While thin Caucasian and Asian women remain at highest risk, African-American women are not exempt. Even men can be at risk. Certain medical conditions, such as having an overactive thyroid gland, using steroid medications for conditions such as lupus or asthma, or early estrogen deficiency can increase a person's risk. Family history also plays a role: having a close relative with the condition increases a person's risk as well. Factors such as smoking, heavy alcohol intake and minimal physical activity also impact on bone density to varying degrees. The loss of estrogen after menopause accelerates bone loss because estrogen's beneficial effects of maintaining bone integrity are no longer present. A simple and painless way for measuring a person's bone density, and hence their risk of osteoporosis, is a dual-energy X-ray absorptiometry (DXA) test. Taking minutes and using very low levels of radiation, it can give an accurate and reproducible assessment of bone mass in key locations as the lumbar spine (lower back) and femoral neck (hip joint).
Once osteoporosis is diagnosed, treatment begins with making certain there is adequate calcium in the diet to replace that which the body is losing on a daily basis. Current recommended doses are 1000 mg for pre-menopausal, non-pregnant women and 1500 mg for post-menopausal women. The calcium can be part of your normal diet in the form of calcium rich foods, such as dairy products, or from calcium supplements that are easily obtained from your drugstore or health food store. Of equal importance is having sufficient Vitamin D in your diet (between 400 and 800 International Units), again either from fortified foods or a simple multivitamin.
In addition, there are several different alternative treatments available to reverse bone loss. These include estrogen replacement therapy (ERT), selective estrogen-receptor modulators (SERMS) such as raloxifene (Evista), bisphosphonates such as alendronate (Fosamax), and
calcitonins such as Miacalcin. Each treatment carries its own unique advantages and disadvantages and the choice of which one is best would depend upon the particular person's medical history.
Finally, new medications in these and other classes are in clinical trials and may offer even further treatment options in the near future. In the meantime, we have several effective treatments available for this silent but serious condition.
Pulsating Magnetic Therapy For Treating Soft Tissue Rheumatism
Alternative therapy in treatment of rheumatic and arthritic disorders has gained widespread popularity over the past few years as it has for treating a broad range of medical conditions. There is a growing financial impact on the health care market as billions of dollars spent yearly on alternative and complementary medical treatments. In an article published in The Annals of Internal Medicine in 1999, it was estimated that in 1997, 4 out of 10 Americans with chronic conditions made 629 million visits to practitioners of alternative medicine. In a survey by Arthritis Today, in 1999, it was determined that 19% of patients polled chose magnets as a form of therapy. Other modalities included prayer, meditation, glucosamine, massage therapy, chiropractic, metal jewelry and yoga. In the same survey, 85% of the primary care and rheumatologists polled indicated that they believe some alternative therapies may be effective. In orthopedics and rheumatology there are interesting applications for the use of magnets and pulsating magnetic fields. Modern bone stimulators used to treat non-union of fractures in long bones apply pulsed magnetic fields (PEMFs) to stimulate cartilage and bone growth and the fracture sites. This technology had been around for 20 yrs. and has become standard treatment.
The experimental evidence shows that an exogenous electric field can induce current through ionic solutions and affect cell behavior. An externally applied PEMF of varying frequency can induce an electric
current to which cells respond. It appears that the chondrocyte (the cell responsible for cartilage growth) responds best at low frequencies, i.e. up to 15Hz (Hertz). At present, this noninvasive effective alternative to surgery shows success rates of up to 80% in the treatment of ununited fractures. Because of its affect on cartilage growth and bone repair, there may be implications for the treatment of osteoarthritis. Moreover, externally applied PEMFs may be useful in ordinary fractures, shortening the time a patient needs to wear a cast.
In rheumatology there is interest in PEMF because of its effect on cartilage growth and possibly on other connective tissues. There is experimental evidence that PEMFs can
elevate one of the basic chemicals from which cartilage is produced. There also appears to be a beneficial effect on other connective tissue as well. Experiments on rat Achilles tendonitis using 17 Hz PEMF showed superior healing and reduction of inflammation when compared to diathermy. In one study using PEMF, at low frequency and very low power (10 to 50 Gauss of magnetic energy), to treat osteoarthritis of the knee, there was approximately 32% improvement in pain and function. The most commonly used magnets are static magnets which can be applied to various parts of the body or put under the mattress. These magnets are low in power, i.e., between 300 and 900 Gauss and do not pulsate and therefore do not have a frequency. They are very popular but actual effectiveness is still being questioned. One study on pain associated with the post polio pain syndrome reported superior results when compared to placebo.
A new modality to deliver a pulsating magnetic field has recently become available. It has been FDA approved for the treatment of female incontinence. Its original design was in the form of a chair but has been modified to a hand held device which can be placed almost anywhere on the body. It is extremely safe to use with almost no side effects. This device delivers a powerful magnetic field, called Extracorporeal magnetic innervation (ExMi) and can produce muscle contractions by actually inducing an action potential. An action potential is the electrical current which stimulates the nerve and causes the muscle to contract. Static magnetic fields delivered by standard magnets, have become very popular in treating a variety of aches and pains, including arthritis. They do not cause contractions and they range in magnetic power from about 300 to 5,000 Gauss. In contrast, ExMI, delivers 100,000,000 Gauss (10,000 Tesla). This is 20,000 times as powerful as the most powerful static magnet. An MRI machine uses about 1.5 Tesla to create its images. The power of this device enables it to reach 3-5 inches deep into soft tissue. At present, there are only a handful of these devices available for clinical use. I have had the opportunity to investigate the use of this new device in my clinical rheumatology practice. Both my partner, Dr. Stephen Bernstein and myself have completed a pilot study looking at treating soft tissue rheumatism with ExMI. We treated a number of patients with a variety of conditions including sciatica, tendonitis, bursitis, acute muscle spasms and muscle injuries and muscle atrophy (weakness). Patients rated there pain at the beginning and at the end of their treatment course, most patients having about three or four sessions. The results have been impressive and according to the statistician, they were statistically significant in reducing pain. Further studies must be undertaken including expansion of the original trial and additional physiologic studies to further understand how ExMI may actually work. Indeed, magnetic therapy, especially powerful pulsating magnetism may have an increasingly important role in the treatment of soft tissue rheumatism and possibly osteoarthritis in the near future.
The Diagnosis and Treatment of Temporomandibular Joint Disorders and Xerostomia
Temporomandibular disorders (TMD, more commonly called TMJ) and Dry mouth (Xerostomia) occur with increased frequency amongst patients with rheumatological conditions. These disorders can significantly impact upon their quality of life. The daily functions of chewing, eating, opening and closing of the mouth, tasting foods and swallowing can be affected, causing pain and other symptoms as the body attempts to compensate for the loss of the respective function(s).
Temporomandibular Disorders (TMJ) is really an umbrella term for a group of painful disorders affecting the jaw joint and/or its associated structures. It affects approximately 10 million people each year, most of whom are women, the causes of these conditions are varied, in general, however they can result from trauma, malocclusions, nocturnal bruxism (grinding of the teeth at night) and systemic disease. This joint falls victim to the same rheumatic and arthritic disease process that affect the other joints in the body.
Symptoms may include:
- Pain, in or around the area of the jaw, face, and the upper portions of the neck. Headaches and earaches are also common and can accompany this condition to some extent.
- Jaw Joint Noise, is another common occurrence. It can range from a soft rubbing sound to a more staccato grating sound (known as Crepitus).
- Altered function, which can involve difficulty with chewing, pain in the jaw upon yawning, a sensation that the jaw tires
easily from chewing or talking, difficulty in opening the jaw to its former extent, or in some cases, locking of the jaw in the open position.
Diagnostic Spectrum
In General, the diagnoses are grouped into those that affect the inner working of the joint and opposed to disorders that affect the tissues around the joint, such as the muscles, ligaments and tendons, that guide or influence jaw function.
Treatment modalities are also varied and specific to the diagnosis, these modalities can include; Intra-oral Orthotic appliances, physical therapy, injections, manipulations, medications and, in some extreme cases, surgery. Treatment is complemented with ongoing instructions on awareness of aggravating factors so as to enhance long-term stability and favorable prognosis.
Dry Mouth (Xerostomia)
Xerostomia is an extremely debilitating and frustrating condition for sufferers. It often starts as a nuisance that progressively worsens. Over time, patients encounter increased difficulty with eating, swallowing and speaking. Saliva is often underestimated in its importance and is discounted by people as merely a wetting agent, when in reality it is so much more. In fact, the normal salivary production is approximately 1.5 liter per day! Although it is the decrease in the amount of saliva that first draws the attention, it is in fact the disturbance in the quality of the saliva that actually contributes to the harm. When we view the components of saliva we find it contains digestive enzymes, additionally it has the unique ability to adjust it consistency according to the frictional demands place on the oral tissues and to maintain a balanced Ph in the mouth. The bodies defense mechanism also use saliva as a vehicle to reach the some many corrugated and irregular surfaces that are in the mouth, explaining the increased rates of cavities and oral infection associated with dry mouth.
Once the diagnosis has been made we record baseline salivary flows that will assist in measuring the response to treatment. The treatment or better stated management approach that we use at this time is to first re-hydrate the oral tissue, followed by Ph control, and lastly use medications if indicated to increase salivary gland stimulation and
secretion.
As a team, we at the center, have modified some of existing dosage protocols of the medications used for dry mouth and the results have been very encouraging, with actual increased benefits and decreased side affects.
In closing, this combined effort within the Department of Rheumatology is increasing our collective understanding of the Orofacial and Dental needs of our patients which we plan to share with our colleagues through the professional literature within the next 2-3 years. Conversely, our dentistry colleagues can be made more aware of oral symptoms that may raise the suspicion of an undetected rheumatological disease and direct the patient
accordingly.
Clinical Trials and New Treatments
New effective treatments for arthritis, lupus, osteoporosis and other related autoimmune diseases are now available at the Center for Arthritis and Autoimmunity. Our Ambulatory Clinical Research Center conducts clinical trials and research for new and more effective medications and treatments. Patients enrolled in these studies are able to receive medications not yet available on the market. If you are interested in participating in one of these studies contact the persons at the numbers listed below.
Studies Currently Enrolling:
Rheumatoid Arthritis
- 12 week study of a new COX-2 selective anti-inflammatory
medication for rheumatoid arthritis pain and inflammation.
- National Institutes of Health Multicenter Trial of Glucosamine, Chondroitin Sulfate, or the
combination in knee osteoarthritis. A 6 month study.
- The effects of Enbrel, Arava, and methotrexate on the expression of genes in the blood cells of patients with rheumatoid arthritis.
Osteoarthritis
- 2 year study of a medication that may delay the progression of osteoarthritis of the knee.
- 6 month study of a new TNF inhibitor injected every 2 weeks for rheumatoid arthritis pain and inflammation.
Osteoporosis
- Comparison of an intravenous medication with Fosamax in the treatment of corticosteroid-induced osteoporosis.
Lupus
- Safety of Estrogens in Lupus Erythematosus, National Assessment (SELENA) Trial. This is double blind-placebo con- trol trial to evaluate the safety of oral contraceptives and hormone replacement in women with SLE.
- Efficacy of Cellcept compared to IV Cyclophosphamide in the Treatment of Lupus Nephritis. Patients with biopsy proven membranous or proliferative nephritis will be randomized to receive one or the other treatment, not blinded.
- Efficacy of LJP395 in SLE patients with anti-DNA antibodies and previous history of lupus nephritis. This is a ran- domized, double blind, placebo-controlled trial. Patients are enrolled for 22 months (weekly injections).
- Observational Trial of Pregnant women with Antibodies to either SSA/Ro or SSB/La. Weekly echocardiograms begin- ning at 6 weeks. The goal is to identify early lesion predictive of advanced heart block.
- Efficacy of dexamethasone compared to placebo for pregnant women who are carrying a fetus with congenital heart block. Weekly echocardiograms.
- SACS: This trial is a year-long study, involving the use of a novel laboratory testing named C3a to predict increase lupus activity (flare).
- Inception Cohort of SLE (newly diagnosed patients) to establish cardiovascular risk factors.
For more information call the ACRC at 212 598-6613.
Really? Children get arthritis?"
This comment is often made when patients at the Center for Arthritis and Autoimmunity see children in the waiting room. The answer, of course, is yes, children do get arthritis, as well as other immune disorders. Indeed, some statistics have shown that 1 in 500 children get some form of arthritis.
Arthritis is the term used to describe inflammation and swelling of the tissues in a joint. These are many different causes of arthritis in children, including a bacterial infection, a drug reaction or an autoimmune reaction.
Bacterial infection within the joint, known as septic arthritis, is a relatively uncommon cause of arthritis. However, this type of arthritis requires urgent care because bacterial infections can rapidly and permanently damage joint tissue. If a child has fever, and severe pain and arthritis in a single joint, determining whether the joint is septic is paramount. The physicians must take a sample of fluid from inside the joint and examine it for the presence of bacteria by cultures and microscopic examination. Bacterial, or septic, arthritis can be cured by antibiotic treatment.
The most common cause of arthritis in children is termed "post-viral arthritis". Typically, a child may have a mild upper respiratory infection or common cold and a week or two later develops one or more painful, swollen joints. The arthritis may last for a few days or even several weeks but passes without any permanent damage. Any virus can cause an arthritis but the most common provocateurs are parvovirus, the agent of Fifth's Disease, and Epstein Barr Virus, the agent of infectious mononucleosus. Drugs such as ibuprofen or naproxen help diminish the pain or swelling.
Intermediate in frequency between these two types of arthritis is Juvenile Idiopathic Arthritis (JIA), a new term for what has been called juvenile rheumatoid arthritis or JRA. Juvenile Idiopathic Arthritis is an "umbrella" term for several different patterns of arthritis in children. They all appear to be caused by an autoimmune reaction-that is, the body fighting its own tissue as if it were a foreign substance. Most frustrating to the parents (and the physician as well!) is that there is no lab test that diagnoses JIA. Rather, it is diagnosed by putting together many facts such as the age of the child, the presence of associated arthritis or other disorders in the family, which joints and for how long the joints have been tender and swollen and which (if any) laboratory tests are abnormal. To make a diagnosis of JIA, the arthritis must be present for at least six weeks without any other cause of arthritis being found. Once sufficient time has passed and the physician evaluates various laboratory tests and x-rays, the arthritis can be classified among at least seven different types of JIA, each having a somewhat different course.
In past, the prognosis of children with juvenile arthritis has always been somewhat guarded. The more joints that were involved, the more likely the children would suffer permanent joint damage, even if they eventually outgrew the autoimmune arthritis. However, with the increased use of methotrexate coupled with newly discovered biologic agents such as etanercept and possibly infliximab, such pessimism seems unwarranted. We encourage people to look at juvenile arthritis as a controllable disease. And, with further research into the cause(s) of these disorders, a cure may be possible in the foreseeable future!
Complementary Medicine Programs
Sponsored by the Hospital for Joint Diseases
By: Suzanne Schry, Administrator of Rehabilitation Services
The Hospital for Joint Diseases is offering several exercise classes to the community. Below is a listing of the programs.
Tai Chi:
The ancient Chinese art of Tai Chi is widely practiced as a means of enhancing mental and physical well being. It is a combination of martial arts and moving meditation. An essential component of Tai Chi is the cultivation or "Chi" (pronounced Chee) throughout the body.
In Chinese, Chi means both breath and vital energy, and the benefit one derives from Tai Chi as a preventive and therapeutic exercise depends on guiding movements with consciousness rather than with force. Tai Chi emphasizes learning one's center of gravity and maintaining it during movement. Learning Tai Chi is the beginning of what can become a fascinating journey of self-improvement and self-discovery.
Strength and Conditioning Class:
This class will focus on specific strengthening exercises for the arms, legs and torso using a combination of free weights, resistance cords and one's own body weight. Strong emphasis will be paced on technique and form to ensure safety and effectiveness. This is a one-hour energizing class in a relaxed and non-intimidating setting.
Chair Yoga:
Hatha yoga is an ancient system of exercises designed to promote physical and mental balance. Although it is thousands of years old, yoga is the perfect antidote to the stresses of modern life. Yoga practice improves flexibility, concentration, patience, perseverance and strength, and may decrease back pain, insomnia, headaches, and anxiety and other stress-related disorders.
Anyone can practice this form of yoga. All that's needed is yourself and sometimes a chair. This six-week course will present an eclectic blend of yoga techniques, all modified to be done sitting on a chair, and is appropriate for people with all levels of physical ability.
For more information, please call Andrea at 212 598-6369.
New and Noteworthy
We congratulate our department chairman, Dr. Steven B. Abramson upon his recent appointment as the Director of the NYU Division of Rheumatology. Dr. Abramson, will assume this position while continuing his other duties as Chairman of the Hospital for Joint Diseases Department of Rheumatology and Medicine, Vice Dean of Medical Education NYU School of Medicine, and member of the Advisory Committee, Center for Drug Evaluation and Research (FDA).
This portents good news for our staff and patients as it is an important step in unifying the Rheumatology programs of both the Hospital for Joint Diseases and the NYU School of Medicine and will allow us greater collaboration on clinical reserach and patient care.
Support Biomolecular Research
Become a Member of the HJD Research Cures Society
$1,000 Associate Member
Associate Members will be invited to seminars given by our faculty. Topics will include arthritis treatments and research projects. Members will also receive additional publications and be recognized in upcoming issues of our newsletter.
$5,000 Research Partner
Research Partners will be invited to seminars given by our faculty and be given a tour of our research labs and facilities. Research Partners will also receive publications and be recognized in upcoming issues of our newsletter.
$10,000 Guardian
Guardian members will receive full membership privileges and will be invited to personal briefings by senior faculty members on research and current medical advances.
All gifts are tax deductible. We also accept gifts made through transfers of securities, charitable trusts, estates, bequests, and annuities.
For more information call
Simcha Feuerman,
Director of Planning at (212) 598-6543
HJD Rheumatology Department Faculty:
Steven B. Abramson, MD
Bertha Bauer, MD
H. Michael Belmont, MD
Stephen Bernstein, MD
Clifton O. Bingham III, MD
Jill P. Buyon, MD
Michael Colin, MD
Robert Fafalak, MD
Brian D. Golden, MD
Kathleen Haines, MD
Stephen Honig, MD
Sicy Lee, MD
Laureano Lopez-Garrido, MD
Michael Pillinger, MD
Lanny Schwartzfarb, MD
Harry Shen, MD
Bruce Solitar, MD
Gary Solomon, MD
Omar F. Suarez, DMD
Chung-E Tseng, MD
Stanley Wallach, MD
Gary Zagon, MD
Research Cures Society
Guardian Member
The Joseph and Sophia Abeles
Foundation
Jane Falk
Eugene Giscombe
The Daniel and Joanna S. Rose
Fund
Sandford Schwartz and the
Schwartz Family Foundation
Research Partner
Norma and Gordon Smith
Christopher Luce
Mr. and Mrs. Robert and Alice
Landau
Mr. Leonard Feinstein
Associate Member
Franklin Lee
Elizabeth Hung
Charles Baum
Rehana Shakur
Randi L. Miller
Arthur Schwabe
Michael Walsh
Don and Marilyn Hewitt Fund of NY
Wm. W. Driscoll
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