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Physicians Update

 
Summer 2009

Conventional and Complementary Therapies Combine to Improve Care for Patients with Rheumatologic Disorders

07/22/2009

Rheumatologic DisordersThe presence of numerous co-morbidities and symptoms in patients with rheumatologic disorders such as inflammatory arthritis, osteoarthritis and lupus often complicates the ability to pinpoint the underlying problems. This also makes providing long-term relief more challenging, but physicians are finding new ways to increase diagnostic precision, as well as to improve and complement conventional treatment strategies for rheumatologic disorders.

Standard diagnostic techniques are not always conclusive, explains Mihaela Taylor, M.D., an internal medicine and rheumatology specialist at Santa Monica-UCLA Rheumatology. “We may have a situation in which the patient’s clinical history and symptoms suggest possible early inflammatory arthritis, for example, but findings from the physical examination, blood tests and x-rays do not yet detect the disease,” she says. Computed tomography (CT) and magnetic resonance imaging (MRI) improve diagnostic accuracy, but these studies are expensive and often contraindicated for some patients. As an alternative, says Dr. Taylor, ultrasound is emerging as a preferred imaging modality for evaluating rheumatologic disorders.

Through dynamic-imaging technology, ultrasound enables physicians to immediately answer specific questions regarding the underlying anatomy and pathology that may otherwise go undetected when using static imaging methods such as CT or MRI. In addition, clinical studies have demonstrated that ultrasound is much more sensitive than x-ray in the early diagnosis of rheumatoid arthritis (RA), the most common form of inflammatory arthritis. Ultrasound findings of synovitis, tenosynovitis (see picture above) and erosions in the affected joints will help the rheumatologist in the early diagnosis of the disease.

“Ultrasound is safe, noninvasive, cost-effective, well-tolerated by most patients and can be conveniently performed at the bedside during the physical examination,” Dr. Taylor says. “These benefits, in addition to proven diagnostic and therapeutic effectiveness, make ultrasound extremely valuable in decision-making regarding therapeutic management of rheumatologic patients.”

The most commonly used treatments for rheumatologic disorders include medication therapy, physical or occupational therapy, diet and exercise management and, in some cases, pain anesthesia, ultrasound or fluoroscopic-guided injections or surgery for joint repair or replacement. A promising medication breakthrough is the development of tumor necrosis factor (TNF) alpha inhibitors, a class of biologic agents with the potential to halt the pain and swelling associated with RA (clinical remission) as well as the progression of the disease that eventually produces physical joint deformities (radiographic remission). Older drug therapies for RA have achieved clinical but not radiographic remission, Dr. Taylor explains. Newer therapies for osteoarthritis, such as hyaluronic-acid injections, are also becoming more widely used, and combination of pharmacotherapy using three newly approved medications for fibromyalgia along with aquatic therapy is benefiting patients with myofascial pain, which is a common manifestation in rheumatologic disorders.

RheumatologyIn addition to providing a full range of advanced and effective conventional therapies, UCLA integrates complementary methods such as acupuncture to treat rheumatology patients. “Acupuncture addresses the physical aspects of pain as well as the emotional and psychological aspects of pain present in chronic illnesses, which is an approach sometimes missing in conventional medicine,” says UCLA rheumatologist and acupuncturist Smita Rani Gupta, M.D.

While acknowledging that some physicians may be skeptical about the therapeutic effectiveness of acupuncture, Dr. Gupta points out that an increasing body of research using functional MRI, considered an objective way to measure neural activity in the brain, has demonstrated that specific areas of the brain are being activated or deactivated when acupuncture needles are placed. “The parts of the brain that mediate the release of the body’s own natural pain killers are activated, while the areas that sense pain are deactivated,” she explains.

Dr. Gupta cautions, however, that acupuncture can have limits. “Arthritis can be quite debilitating and destructive if inadequately managed, and it is not feasible to manage autoimmune or inflammatory diseases with acupuncture alone,” she says. “In my experience, the addition of acupuncture attenuates the severity of the rheumatic diseases and conditions and, as a result, patients have greater responses and require less medication.”

For more information about rheumatology at UCLA, go to:
www.rheumatology.ucla.edu





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