Alternative medicine simply refers to those treatments and health-care practices that are not taught widely to physicians training in the United States today. They are rarely used in hospitals and are not usually reimbursed by medical insurance companies. Often termed "unconventional", they are outside of the mainstream of Western medicine practice and include the use of herbs or other natural healing therapies. "Complementary medicine" refers to similar therapies being used along with Western medicine techniques. This is the preferred method of many physicians to utilize alternative treatments.

The herbal market in the United States has experienced dramatic growth since the passage of the Dietary Supplement and Health Education Act of 1994, which allowed dietary supplements to be sold without approval from the Food and Drug Administration. In 1997, herbal medicine sales increased 59% with 60 million Americans reporting use of herbs. This accounted for approximately $3.25 billion in sales. That same year nearly $27 billion was spent on all forms of alternative therapy.

Acupuncture originated in China over 5000 years ago and is based on the belief that health is determined by a balanced flow of energy in all living organisms. This vital flow circulates in the body along 12 major pathways, termed meridians, and each meridian is linked to internal organs and other bodily functions. There are over 1000 acupuncture points that can be stimulated to enhance this vital flow of energy and thereby improve health. The National Institutes of Health recently endorsed acupuncture for relief of nausea from chemotherapy and pregnancy, and pain relief from dental surgery. It is used in

many parts of the world for arthritis. Some research suggests it can help to control different forms of chronic pain.

Chiropractic is an interventional field that deals with the relationships between the bony vertebral column (spine) and other musculoskeletal structures and their effect on the nervous system, other organs, and the general function of one's body. In a state of good health, the vertebral column operates smoothly, but with disease there is felt to be vertebral misalignment and a disruption of bodily function leading to problems such as muscle spasm, headache, and chronic pain. Most patients see chiropractors because of low back pain, and a 1990 British study found chiropractic treatment more effective than outpatient medical therapy for low back pain. Chiropractic is widely practiced in the United States, and many hospitals and physicians currently work with chiropractors. However, chiropractors cannot prescribe medications, and many have aligned themselves with alternative herbal remedies. This has raised suspicion among the conventional medical establishment.(CONTINUED HERE)

Practitioners of herbal medicine use plants or parts of plants to make medications. Herbs contain many naturally occurring chemicals that are active in our bodies when ingested. Although many have not been adequately studied, some herbs are currently used such as digitalis for heart failure patients (from the purple foxglove plant). Herbs are used to treat many conditions and come in various forms such as teas, capsules, tablets, extracts, tinctures, and ointments.

S-adenosylmethionine (SAM or SAMe) has been tested in patients with knee osteoarthritis (OA), and one study found that it reduced pain compared to a sugar pill (placebo) in patients with mild OA. Other studies from Europe imply that it may work as well as ibuprofen to treat OA pain. MSM (methyl sulfonyl-methane) is a supplement touted as a cure for arthritis. It is derived from DMSO and is reported to be non-toxic. It supposedly acts to boost the immune system and may, therefore, prevent some infections. It apparently has minimal side effects such as an unpleasant taste. However, some patients with an overactive immune system, such as those with diseases like lupus, should be careful with such herbal remedies. It is possible that "stimulating" the immune system may worsen the underlying disease. Ginseng is another agent that has been promoted to reduce fatigue and even fight cancer. It is an extremely popular supplement, but there is no evidence that it helps patients with arthritis.

Approximately 3 to 6 million adults in the United States have fibromyalgia. Common symptoms include generalized muscle aches and pains, stiffness, fatigue, and unrestful sleep. Medical intervention usually involves a team of health care professionals who focus on interrupting the pain cycle, improving physical fitness, and restoring normal sleep patterns. Physical therapists are specialists in exercise and pain management. A physical therapist with experience treating fibromyalgia can serve as an important member of the health care team.

Regular exercise can lead to improvements in joint flexibility, posture, muscle strength, endurance, pain, sleep quality, and overall functioning. Flexibility, strengthening, and aerobic exercises are recommended for individuals with fibromyalgia. Gentle stretching exercises improve joint flexibility and relax tight muscles. A physical therapist can select the most appropriate stretching exercises and ensure that the exercises are performed properly. For example, persons with fibromyalgia should perform slow, gentle stretching exercises. Each stretch should be sustained for 30 to 60 seconds without causing pain or discomfort.

A physical therapist can also design a strengthening program with specific exercises to strengthen weak muscles. When exercising to improve muscle strength, it is important to be able to distinguish between muscle fatigue and pain. A physical therapist will teach patients how to exercise safely without aggravating their symptoms.

Aerobic activities aimed at improving physical fitness promote a sense of well-being in persons with fibromyalgia. Stationary cycling, aquatic exercise, and walking are ideal types of exercise for increasing aerobic endurance. An exercise program should include 5 to 10 minutes of warm-up exercises before the aerobic activity, as well as a 5 to 10 minute cool-down period at the end of the exercise session. A physical therapist can assist with selecting the appropriate type, frequency, duration, and intensity of exercise, taking into consideration that individuals with

fibromyalgia generally have a delayed response to exercise. (The effects of exercise may not be felt until 1 to 3 days after). As a result, the muscles may require longer rest periods to recover following exercise. For instance, a physical therapist may determine that an individual should ride a stationary bicycle every other day for 5 minutes with a gradual increase to 20 to 30 minutes per session. The cycling is performed every other day in order to allow an adequate rest period between exercise sessions.

In addition to providing recommendations for exercise, a physical therapist can give advice on techniques to reduce pain at home, such as the proper use of hot packs, cold packs, and massage. A physical therapist can also provide helpful hints on pacing of daily activities, safe lifting techniques, good posture, sleep positioning, methods for conserving energy, and relaxation exercises.

The overall goal of physical therapy is to teach individuals how to "self-manage" their fibromyalgia symptoms and adjust their activities so that they can continue to lead active, productive lives. Talk to your physician if you have questions about whether or not physical therapy is appropriate for you. For information on the Fibromyalgia Physical Therapy Program or the Arthritis Foundation Aquatic Exercise Program at the Centers for Rehab Services, contact Dina Jones, MS, PT, at (412) 578-3300.

Dina Jones, MS, PT

Osteoarthritis is the most common form of arthritis. This degenerative condition involves thinning of the cartilage that normally cushions the ends of the bones. The knee is one of the frequently affected joints in the body. Individuals with osteoarthritis may experience pain, stiffness, and swelling in the knee joint. These symptoms are usually worsened with activity and relieved with rest. In addition, osteoarthritis of the knee may interfere with the ability to perform usual daily activities. Potential limitations include diffuculty walking, squatting, kneeling, climbing stairs, and transferring from a sitting to a standing position.

The medical management of knee osteoarthritis focuses on relieving symptoms and maintaining an individual's functional abilities.Physical therapy may be a benefit. Treatment is aimed at increasing knee joint flexibility and muscle strength, improving cardiovascular endurance, relieveing pain, and reducing stress on the knee joint.

A physical therapist can design a safe and effective exercise program for the knee. Cartilage needs joint motion for its nutrition; thus, the knee should be moved through its full range of motion each day to maintain flexibility and good cartilage health. Another reason for the use of exercise in the treatment of knee osteoarthritis is to increase muscle strength, especially in the quadriceps, or thigh muscles, which are located in the fromt of the thigh and are responsible for straightening the leg at the knee. Strengthening the quadriceps muscles can enhance the stability of the knee and improve walking. Cardiovascular endurance exercises, such as swimming, stationary cycling, or walking should also be included in the program. These types of aerobic activities can strengthen the quadriceps muscles, enhance stair climbing, improve physical fitness, increase walking speed, and decrease pain in the knee.

A physical therapist can suggest ways to reduce stress on the knee joint, such as carrying lighter loads, maintaining appropriate body weight, avoiding stairs, and exercising in water. Walking with a cane can also decrease stress on the knee joint by at least 20 percent. Canes, walkers, and other aids can be obtained in a physical therapy department if needed. A physical therapist can also teach individuals with knee osteoarthritis how to use hot packs and cold packs at home to control pain, stiffness, and swelling of the knee.

Individuals with knee osteoarthritis need to use their energy as efficiently as possible. A physical therapist can explain the principles of energy conservation, including prioritizing, pacing, and planning activities, as well as balancing physical activity and rest. By applying the principles of energy conservation to daily activities, persons with knee osteoarthritis can conserve their energy for the more important tasks in life. Finally, orthopaedic surgery is sometimes necessary to derease knee pain and improve function. Physical therapy plays a crucial role in the pre- and post-operative management of patients undergoing surgery by educating patients on the proper way to walk and exercise after surgery.

Osteoarthritis is the most common form of arthritis and the second most common cause of long-term disability among adults in the United States. Obesity is one of the risk factors for developing osteoarthritis and correlates best with osteoarthritis of the knee. Also, obesity is a risk factor for diabetes, heart disease, and other diseases that can interfere with the management and ultimately the outcome of patients with osteoarthritis.

UPMC's Weight Management Center is the only program in the region that provides comprehensive, medically supported services for the treatment of obesity. Through the center, patients are evaluated on the basis of past weight loss attempts, medical and psychological histories, and current exercise activities. Patients are then directed to one of several weight management programs that provide lifestyle modification, medications, and specialized surgical services alone or in combination. Some medications that have become available recently carry less risk as compared to other appetite suppressants. Also, laparoscopic surgical procedures can be offered to some patients and are less invasive.

BMI (Body Mass Index) is a widely used index that can help you know if you are overweight or not; all you need is your height and weight, and with the help of the table, you will know where you stand.

Underweight range is 18.4. Normal weight range includes BMI from 18.5 to 24.9 Overweight is defined as BMI from 25 to 29.9. People with a BMI over 30 are obese; those whose BMI is over 40 are considered severely obese.

For more information about the Weight Management Center, you can call (412) 624-2339 or discuss the issue with your doctor at your next office visit.

Ghassan Alayli, M.D.

Infliximab (Remicade) is an antibody that represents the newest addition to the arsenal against rheumatoid arthritis (RA). Like Enbrel, Remicade works by blocking the effects of TNF (tumor necrosis factor), a protein responsible for triggering much of the inflammation in RA. In a large, multicenter trial called ATTRACT (Anti-TNF Therapy in Rheumatoid Arthritis patients on Concomitant Therapy), investigators compared various doses and treatment intervals in 428 RA patients to determine the most effective regimen. They found that in patients also receiving methotrexate, a 3 milligram/kilogram intravenous dose of Remicade (about 200 milligrams for 150 pound person) given at weeks 0, 2, 6, and then every 9 weeks thereafter resulted in significant reduction of inflammation over a one year time period. In addition, joint X-rays showed an arrest in the destruction of bone (erosions) compared to methotrexate therapy alone. Side effects were minimal and included headaches, upper respiratory infections, and infusion reactions (itching, rash, and hives) in a small percentage of patients. Although long-term studies with Remicade have not yet been completed, the initial trials involving over 600 RA patients have not shown increased risk for serious infections or malignancy with this drug. Because Remicade does suppress the immune system, however, this treatment may not be appropriate for patients with underlying illnesses that can predispose to infection (such as diabetes, heart failure, or kidney failure). Whether Remicade is safer or more effective than Enbrel in RA patients is not yet clear, as these treatments have not been compared head-to-head. For more information about this encouraging new treatment, ask your doctor.

Dana Ascherman, M.D.

The physicians in the UPMC Arthritis Network have developed an Arthritis Network Registry to aid investigators in arthritis research. The purpose of this Registry is to compile and organize a list of patients who have rheumatic diseases and who are interested in hearing about research studies for which they may be eligible to participate. The Registry is generously funded by the St. Margaret Memorial Hospital Foundation.

How does the Registry Work?

Once a person has agreed to participate in the Registry, his/her name, address, date of birth, and diagnosis are entered into a computer database. When a physician decides to conduct a study on patients with a particular rheumatic disease, such as fibromyalgia, he or she can apply to the UPMC Arthritis Network Research Committee for permission to utilize the Registry. After University of Pittsburgh approval is obtained, and the Research Committee agrees that the research is scientifically sound, then the physician can receive a list of names and addresses of Registry participants. Then either the physician or a member of the research team contacts the Registry participants with specific details of that study.

As participants in the UPMC Arthritis Network Registry, patients are under no obligation to participate in any of the studies. When agreeing to become part of the Registry, patients are merely consenting to being contacted with information about upcoming research studies. Patients may remain members of the Registry regardless of whether they have decided to join any studies in which they are invited to enroll. Registry participants receive both study announcements and informative newsletters such as this one.

Development of the Registry

The first step in developing this Registry was to recruit patients with rheumatoid arthritis. The Arthritis Network Registry now includes over 800 patients with rheumatoid arthritis and over 600 patients with osteoarthritis. This is a tremendous response; it indicates strong patient interest in research involving their diseases.

Due to the success in recruitment of rheumatoid arthritis and osteoarthritis patients, the Arthritis Network Registry will begin to recruit patients with fibromyalgia beginning in April of 2000. Patients who have been diagnosed with fibromyalgia should watch their mail for an information packet sent by their rheumatologist. This packet includes a letter of invitation to join the Registry, a consent form, a newsletter, and a return envelope. The letter of invitation gives further information regarding the Registry. In order to participate in the Registry, the consent form must besigned and returned as directed. Signing the consent form simply gives researchers who are authorized by the UPMC Network Research Committee consent to contact individuals regarding specific research projects and opportunities to participate in them.

Joining the Registry

In addition to the new fibromyalgia recruitment, the Registry also remains open to all rheumatoid arthritis and osteoarthritis patients. Jennifer Jablon, the Registry Coordinator, is abailable at (412) 383-8674 to answer any questions or to mail an invitation to participate in the Registry. Applications are also available on the website, http://www.arthritis.pitt.edu.

The Registry office has recently been moved to the University of Pittsburgh Arthritis Institute, which is located at 7 South BST, 3500 Terrace Street, Pittsburgh, PA 15261.

Jennifer Jablon

Marshall S. Levy, M.D., born June 8, 1928, died on October 31, 1999. He graduated from the University of Pittsburgh School of Medicine in 1953 and subsequently completed his internship at Montefiore Hospital in Pittsburgh and residency at Mt. Sinai Hospital in New York. In 1957, he joined Dr. Paul Caplan in the practice of Internal Medicine and Rheumatology, now called Arthritis and Internal medicine. Dr. Levy leaves his wife, Lois, a son, two daughters, and a newly born granddaughter who made him proud to be a grandfather.

Professionally, Dr. Levy was a physician with the personality of a "Renaissance man". He was a talented musician and versatile jazz pianist, but he also enjoyed classical music. His interests were varied and his knowledge extensive beyond the practice of medicine. As an expert photographer, he saw every occasion through his many cameras. He knew the Bible and would discuss its message for hours with his pastor patients.

Dr. Levy was an excellent physician who practiced the art of medicine with love for humanity. Bonding with his patients, he reached out to them by participating in their lives, their tragedies, and their joys. He experienced their pain and sorrows, serving as their friend and confidante. Dr. Levy was also a man of great personal courage. Aware of his illness and the premature death that it would cause, he nevertheless maintained an optimism, a zest for the practice of medicine, and a joy of living. Marshall Levy will be missed by his family, his colleagues, and most of all, by his loyal patients.

Paul S. Caplan, M.D.

Editor's Note: In recognition of Dr. Margolis' contributions, the Arthritis Foundation, Western PA Chapter has designated the highest ranking research grant funded by the Chapter each year as he Harry M. Margolis Research Grant (see article on page 1 about the grant and its first recipient, Dr. Dana Ascherman).

On Friday, May 19, 2000, from 1:00-4:00 p.m., the UPMC Alive and Well Program presented an afternoon of talks on fibromyalgia, co-sponsored by the Arthritis Foundation. Included were an overview of fibromyalgia by Dr. Terence W. Starz, complementary medicine approaches to treatment by Dr. Ronal Glick, and presentations by a pharmacist, physical therapist, and occupational therapist on stress management and strategies to improve sleep. The program will be summarized in the next issue of the Newsletter.

Jennifer Jablon