INFO - Inflammatory arthritides: what can the doctor of chiropractic offer?

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Journal of the American Chiropractic Association

March 2004

" Inflammatory Arthritides: What Can the Doctor of Chiropractic Offer?

Excerpt:

A patient comes to her doctor of chiropractic's office, complaining of a

persistent stiff neck. She's in her mid-30s, active, generally healthy, and

has no other pains or symptoms to speak of-although she mentions she's been

tiring more easily of late. The neck pain, she says, has been going on for a

few weeks now. Aspirin can sometimes relieve it for a time, but then the

pain and stiffness return-and they've been getting worse. Plain film x-rays

don't show anything out of the ordinary.

Most doctors of chiropractic, says Kurt Wood, DC, professor and chair of the

College of Chiropractic at Northwestern Health Sciences University, might be

expecting something simple, like a repetitive strain injury. " When you see a

four-legged animal in Minnesota with a long mane and a tail, you think of a

horse, not a zebra, " says Dr. Wood. " The patient's getting closer to middle

age, and we all have a tendency to develop more kinks as we get older. So

you treat the person, probably doing a typical course of manipulation-and

she gets worse. "

That's because the patient has something far more complex than a repetitive

strain injury. She has rheumatoid arthritis. The most common of several

types of inflammatory arthritides, rheumatoid arthritis is a systemic

disease. Characterized by inflammation of the synovium, the membrane lining

the joint, rheumatoid arthritis most commonly affects the hands, the wrists,

and the neck, although its characteristic inflammation can also produce pain

and stiffness in the feet, ankles, elbows, shoulders, knees, and hips.

Like a number of other autoimmune diseases, such as lupus, rheumatoid

arthritis is much more common in women than in men-women develop it at about

twice the rate men do. (About 2.1 million Americans have rheumatoid

arthritis-1.5 million women and 600,000 men.) And it tends to present at a

much earlier age than osteoarthritis, usually showing its first symptoms

between the ages of 30 and 50.

Because the typical patient is fairly young and often in otherwise good

health, she's likely to attribute her soreness and joint pain to a condition

that might well be treated with chiropractic, such as sports injuries,

repetitive strain, or disc problems. " A lot of people present to their

chiropractor with that initial neck pain, never suspecting rheumatoid

arthritis, " says Dr. Wood. " That's where the DC needs to be aware of what

could be happening. You often make the assumption that they don't have

rheumatoid arthritis, although it should be in the back of your mind. If the

patient fits the demographic, ask about hand discomfort-if there's stiffness

in the wrists, hands, or fingers. "

The patient may report no other suspicious symptoms to point toward

rheumatoid arthritis, however, and its early changes rarely show up on

x-rays. One sign that rheumatoid arthritis may be involved is if the

chiropractic adjustment leaves the patient feeling worse, not better. " If

you adjust the patient at 9 a.m. and she calls back at 1 p.m. saying, 'What

did you do to me? I'm miserable,' you need to consider rheumatoid

arthritis, " says Dr. Wood. Chiropractic adjustment, for the rheumatoid

arthritis patient, irritates the synovial joints and causes a flare-up of

the condition.

If the chiropractor suspects rheumatoid arthritis, other tests come into

play. Should the chiropractor handle those personally, or refer to another

practitioner? " This is a big bone of contention in chiropractic, " says Dr.

Wood. " My personal hope is that they'd have, at their disposal, the ability

to obtain the blood samples either in their office - I had to do that while

practicing in a rural area - or cooperatively with their local hospital or

local lab. A number of chiropractors would probably say, 'I don't want to

deal with this condition. I'm going to refer it out.' That's one opinion,

but I think that's not the right choice. "

Why not? For one thing, the patient may well not have rheumatoid arthritis.

" Sometimes that's just the nature of the animal. I prefer not to send a

patient for an expensive specialist visit without a clear indication that

that's where he or she needs to go, and the way to do that is to obtain some

very simple blood serologies, " says Dr. Wood. The panel of diagnostic tests

includes a standard rheumatic or arthritic profile, a test for rheumatoid

(RA) factor, antistreptolycin titer, and antinuclear antibody (ANA) testing.

For gout-another of the inflammatory arthritides-the chiropractor would also

do a clinical chemistry for uric acid.

" Of course, you'd also obtain an erythrocyte sedimentation rate, which is a

general inflammatory test, " says Dr. Wood. The test assesses the settling of

red blood cells in a tube over a period of one hour. ESR is increased in

rheumatoid diseases, most infections, and in cancer; the highest ESR values

are found in rheumatoid arthritis and in multiple myeloma. " It's nonspecific

for a particular disease, but it's very good at telling you if there's some

significant inflammatory process going on in the body.

Also, you'll want a complete CBC because very often there's anemia present

in cases of rheumatoid arthritis. " Another test that's good for determining

the general inflammatory rate in the body is the CRP, or c-reactive protein.

" Triaging the patient and discovering an inflammatory condition, such as

rheumatoid arthritis or another type of inflammatory arthritide, is an

extraordinarily important service that the doctor of chiropractic can

provide, " says Dr. Wood.

That doesn't mean that once rheumatoid arthritis is diagnosed, the

chiropractor is no longer caring for the patient. Although the patient

should be referred to a rheumatologist, the chiropractor can still play an

important role in helping manage the condition. " We can provide great

palliative relief for those individuals, which will mean a great deal to

them, " says Dr. Wood. " We can effectively cure many people. You know they'll

get better fairly quickly. You can contribute to the improvement of their

quality of life. That's enormous. "

Nutritional Approaches to Rheumatoid Arthritis

" The focus of treatment, whether you take a complementary or conventional

approach to rheumatoid arthritis, is the same. First, you want to slow the

progression of the disease by causing some sort of disconnect in the

autoimmune response, and second, you want to manage the inflammation, " says

Pins, PhD, MS, MPH, LN, director of a research clinic at the University

of Minnesota Medical School and adjunct associate professor at Northwestern

Health Sciences University. " The inflammation causes pain, of course, but it

also leads to progressive tissue damage. "

A conventional medical approach might combine pain medications such as

NSAIDs and corticosteroids with the powerful DMARDs-disease -modifying

anti-rheumatic drugs-that suppress the immune system and slow the

progression of the disease. But powerful drugs come with powerful side

effects and DMARDs are no exception; a number of them can also be

contraindicated for patients with conditions such as liver or kidney

disease.

There is some evidence that nutritional medicine can play a role in

controlling the inflammation, and possibly also in slowing the progression

of the disease, according to Dr. Pins.

" Research in nutritional medicine related to rheumatoid arthritis focuses

keenly on two specific areas: the first uses supplemental fatty acids and

the second is based more in botanical medicine, " Dr. Pins explains.

The three fatty-acid supplements most commonly used in a nutritional

approach to rheumatoid arthritis are eicosapentaenoic acid (EPA),

docosahexaenoic acid (DHA), and gamma linolenic acid (GLA). " The reason they

are used is that they provide alternative substrates for phospholipase

A2-which is exactly the same thing that corticosteroids do. They block

phospholipase A2, " says Dr. Pins. " So, rather than taking a drug that blocks

this pathway, you take a fatty acid that causes the body to produce

different end metabolites. You get the same bang for your buck, but not the

side effects like immune problems and bone loss that you get from

corticosteroid therapy. It really is unique; there's nothing else you can do

to provide different substrates for phospholipase A2 than to give these

fatty acids. "

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