Rheumatology: Pain, Joints, and Autoimmunity

I just finished my final elective of medical school. I chose Rheumatology because I have such a strong genetic tendency towards this class of diseases, and because it was something I felt under-educated about heading into Internal Medicine.

Rheum itself means “a watery fluid that collects in or drips from the nose or eyes.” Whereas rheumatism is “any disease marked by inflammation and pain in the joints, muscles, or fibrous tissue, especially rheumatoid arthritis” according to online dictionaries. Clearly these two do not match up? Although perhaps one could argue it is the “watery fluid” of the joints that is attacked by immune system dysregulation in most of these conditions, resulting in pain, inflammation and joint destruction. Most of these conditions are also multisystemic, affecting the heart, lungs, kidneys, eyes, skin and more. The umbrella of rheumatology is large: conditions I saw in clinic included rheumatoid arthritis, lupus, scleroderma, psoriatic arthritis, polymyositis and dermatomyositis, pseudogout, gout, and polymyalgia rheumatica. There are of course more that I did not witness.

A large part of patient management involves managing and regulating pain. Opioids are now recognized as crutches inhibiting recovery for many people with long term pain rather than panaceas. Dr Clauw, a pain specialist from Michigan explains this way better than I could, and also addresses several prescription and over the counter medications as well as lifestyle management techniques for living your best life with chronic pain. Watch this YouTube video now, or listen to it while you drive: https://youtu.be/B0EhNajqkdU 

One conversation that came up several times was the use of topicals for pain. Many folks cannot take ibuprofen for pain due to stomach or kidney disease, or are already on long term therapy with prescription strength NSAIDS and still have pain. Voltarin, a topical NSAID was prescribed regularly, specifically for osteoarthritic pain at the base of the thumb with good success.

Many patients use CBD preparations for consistent pain reduction. Some people call cannabiboids “opioid sparing medications” as people can reduce the amount of narcotics needed on a daily basis with the concurrent use of CBD products. The doctors I was working with did not specifically endorse nor did they advise against medical marijuana as Maine is a state where purchase and possession is legal with certification. However, they did support individuals trying topical marijuana preparations of their own initiative for pain management.

The biochemistry of cannabinoids is super interesting if you are into psychoneuroimmunology. This recent article from Naturopathic Doctor News and Review does a pretty good job of outlining the basics of CBD oil as well as some of its politics in reference to mental health. Its use in pain management is multifactoral. There are two main cannabinoid receptors in the human body both of which are relevant to rheumatology and management of chronic inflammatory, neuropathic and mechanical pain. CB1 receptors are found throughout the brain and body and are responsible for most of the psychotropic effects; they are also found on osteocytes (bone) and chondrocytes (cartilage). CB2 receptors are primarily on immune cells  as well as osteo and chondrocytes. The underlying physiology is complex and still being researched extensively but one thing is clear: cannabis-based medications are effecting in reducing chronic pain via their effect on the the endocannabinoid system in humans and altering pain chemical signalling.

As aggressive autoimmune diseases, most of these conditions require sophisticated, high end medications to manage their progression. I saw many cases of men and women who had life changing benefits from DMARDS, or Disease Modifying AntiRheumatic Drugs. My main take home point from this rotation was if one of my patient is newly diagnosed with one of these conditions, REFER! to a rheumatologist as the medications are advanced and specific. My great-grandmother was bed-bound by 40yo with rheumatoid arthritis and she did not have the benefits of science to treat her disease progression. Even tho I am also a Naturopathic Doctor, I have respect for the powerful efficacy of these medications and do believe they improve and maintain quality of life in potentially destructive conditions like these.

On the other hand, medications alone are often not enough to manage and maintain the best health possible. The 2017 textbook I was given for the elective had a small section at the back for complementary and alternative therapies that have good evidence for rheumatology.

  • Vitamin C is an essential component of cartilage and collagen. Supplementation reduced progression of joint and cartilage destruction over time. My Note: Vitamin C is naturally occurring in high levels in many raw fruits and vegetables. This is a great reason to eat fresh raw foods as part of your every day diet with any kind of inflammation or joint disease.
  • Vitamin D is for more than strong bones; it is also a hormone that effects immune health. Countries that have less sunlight year round have higher occurrences of autoimmune disease. Get outside 20 minutes daily minimum all year round, and supplement vitamin D every winter. Have your blood levels tested every fall to ensure optimal levels of this hormone and nutrient.
  • Fish Oil has known anti-inflammatory properties in its EPA component and many brain benefits in its DHA. This rich omega 3 essential fat is best eaten as a meal at least 3 times per week – a tin of sardines, mackerel or herring has way more nutritional value than a couple of fish oil pills and costs so much less. Any seafood will contain fish oil  – the littler the fish, the higher the benefit when it comes to these healthy oils. If you do go for the fish oil pills know that you get what you pay for. Evidence shows you need about 3000mg of fish oil via pills daily for benefit, or at least 450 mg DHA and 750mg EPA. I like Nordic Naturals Brand for best quality and efficacy if you are going to go the pill route. For tinned fish, there are lots of brands, but this is my fave and it’s easy to find in regular grocery stores.
  • Omega 3 oil is also available in vegetarian form as flax seed oil or marine algae oils.

The evidence for a specific kind of diet for autoimmune disease is variable. Dr Jackson referenced the Mediterranean Diet as the best foundational nutritional plan for Lupus specifically. This makes sense as it is a low inflammatory, high fruit, fiber and vegetable diet with known benefits for heart health and longevity.

Many people choose to go paleo, or follow the whole 30 autoimmune diet plan. Phoenix Helix is a podcast dedicated to autoimmune health and paleo nutrition. During my rotation I listened to a great episode with Dr. Aly Cohen, an integrative rheumatologist who spoke on scleroderma and integrative medical management. In addition to reviewing some specific suggestions for scleroderma, Dr. Cohen spoke on the importance of reducing processed food chemicals, pesticides and additives and choosing clean drinking water, not from plastic bottles. As she said, over 90,000 chemicals have been introduced to the ecosystem and therefore the human body in less than 100 years. Autoimmune disease is linked to this toxic burden and inability to process the chemicals. Find out more about her work @thesmarthuman on Twitter and Facebook.

Three weeks of rheumatology clinic was only enough to learn the basics of diagnosis and management, and gave me great respect for my fellow Rheumatologicial internists. Each of the conditions under the Rheumatology umbrella have advanced immune dysregulation and multisystemic consequences with potentially dire outcomes. Fortunately, pharmacology has a class of exceptional medications that work quite well, especially when paired with nutritional initiatives and long term pain management strategies that focus on quality of life. I am grateful to Dr. Stanhope and Dr. Jackson at Central Maine Medical Center Rheumatology Associates for letting me ask too many questions while they were trying to write notes during their busy clinic days – and for the freedom to enjoy afternoon sunshine on my last medical school rotation!

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Gall Bags, Spring, and Other Mysteries

Has Spring come to your part of the world? Because it is slow to arrive in Maine. Most of our world here is still a monotonous palate of gray, brown, pine green, white, dirty white and cold blue. April has promise, because today the sun felt warm even with the cool wind. And little shoots of yellow-green things are growing in the dirt!

Naturopathic Medicine heralds spring as the season of the liver – like trees stagnant over the winter our saps start to flow too. And our sap in this case in not blood, but bile. The ancient Greeks separated bilious humors into yellow, and black. Yellow bile is what we now call bile, stored in the gall bladder and useful in digestion. Black bile is a far more mysterious, melancholic and deadly humour, and one that I will have to investigate further when I am not studying for surgery exams.

So far this clerkship has been “general surgery” which has been primarily cholecystectomys and hernia repairs. The standard of care is to electively – or emergently – remove every gall bladder that presents with symptoms and evidence of stones or sludge. This makes sense because once one stone has caused problems, its pretty likely another will eventually. Complications can be pretty intense – gallstone pancreatitis with or without ileus is nasty, as is choledocolithiasis and ascending cholangitis. I am on board with this plan.

The best plan of action to avoid having gall bladder surgery is prevention. Inspired, committed lifestyle and nutritional prevention years before the problem starts. Not many people are willing, or have access to the knowledge to practice the kind of prevention that is required to avoidgallstones. By this I mean, too many people are never educated about the impact of food choices on health,  or just dont care enough to make the choices to eat an every day diet with good quality oils, moderate animal proteins and high fiber, high antioxidant, high phytonutrient grains and fruits/vegetables. (This is a whole other conversation about class, nutrition, education, access and economics.) Individuals also need to have the spark of interest to learn about plants as medicine and botanical therapies for liver health, as well as the initiative to either track down someone to act as a herbalist or dabble in self care. Because, once gallstones are formed there are some treatment options but…. not many. And IMHO, not many that are truly effective.

For those out there looking for guidance, herbal medicine combined with nutrition is the best way to maintain long term liver and gall bladder health. According to a PubMed Physiology text, bile is formulated in liver cells and modified by cholangiocytes as it travels through the bile canalicula. It is essentially a watery mix of cholesterol, bilirubin, phospholipids (fats), bile salts (broken down cholesterol bound to amino acids), proteins, bicarbonate, salts, and enzymes like alkaline phosphatase. Bile is classified as a mechanism to eliminate waste from the body, and I suspect it carries dubious products from the CYP enzymes that are not fully metabolized by an overburdened liver as well.


With this in mind, increasing bile flow with bitter alkaloids and other phytochemicals inherent in plant medicine are a logical way to improve gall bladder health. There is one botanical I know that have specific use for stones in the body called peumos baldo, but most of the hepatophillic herbs simply increase bile flow thereby decreasing stagnation and thus stone formation. One well-known liver loving botanicals is milk thistle (silybum marianum), which is insanely hepatoprotective and has multiple studies on it for chemical insults. This will not likely help with bile health directly, but it does protect hepatocytes from repeat insults from drugs metabolized by the CYP enzyme system such as antidepressants, anti-epilepsy drugs, birth control, alcohol, narcotics, and some antibiotics.

Dandilion (Taraxacum officionalis) and artichoke (Cynara scolymus) are often paired for their cholegogue effects. Its very common to see these three together in standardized formulations as they are probably the most well known players – and for good reason because they are safe for most healthy people and have a very long historical use for all sorts of “bilious” afflictions including gall stones. Of note, if you have lots of gall stones sitting in your gall bladder or have already had gall stone attacks,  taking high doses of cholegogues could precipitate an attack of acute cholecystitis. However, if you have already had your gall bladder removed they would be safe. There are many other plant medicines for bilious health employed by Naturopathic Doctors and herbalists world-wide, from many indigenous systems of medicine. Seeing an expert for individualized medicine is always the best choice for safe, effective and appropriate treatment as the liver, like all organs in the body rarely acts in isolation. Thus, the best medicine takes your whole health into account.

Finally, we think of natures medicine as extracted herbal “drugs”, but plain old water is so therapeutic for liver health. If bile is an aqueous solution, then chronic dehydration from caffeine/alcohol soda/sodium must lead to a concentrated and hypersoluble solution, right?

Vegetables are also medicinal plants. Spicy and bitter greens have the same cholegogue activity as dandilion and artichoke and are very safe to consume. Cruciferous vegetables like cauliflower, broccoli, kale and brussel sprouts have documented chemical constituents that improve estrogen metabolism, thereby improving bile flow. The fiber binds excess cholesterol and maintains bowel health, and they have documented anti-cancer properties. Eat your broccoli!  Beets and carrots are rich in carotenoids which give their vibrant colors. These have traditionally been used as healing foods for the liver and although I do not know the exact reason why, can they hurt? Only if you hate beets, I suppose.

I have to stop writing this post, because I have to be up at the crack of dawn for another laproscopic cholecystectomy tomorrow. Its a surgery that definitely needs to be done – the woman has had some significant blockage from a stone that miraculously moved on its own but caused an elevated bilirubin as well as weeks of abdomninal pain and distress. It would be unsafe for her to just wait around for that to happen again, because where there is one stone, there are probably two. And where there is a chronically dehydrated American taking multiple pharmaceuticals and eating the SAD, there will always be another gall bag to take out.

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The Pain Conundrum: Options & Alternatives

I’m a woman with chronic pain. It waxes and wanes, but I have been on flourbiprofen, a prescription-strength NSAID for about 20 years. I take it about a week before and the week of my menses. That is two weeks a month of strong NSAID use. Plus, ibuprofen for occasional headaches or other pains.

After spending a week observing a nephrology office in January, I started thinking about my own NSAID use and  kidney health. After getting some lab evaluation (creatinine, BUN and GFR) it turns out I have stage 2 kidney disease. WHAT!! I consider myself an extremely healthy woman, and no doctor has ever mentioned kidney issues, much less had a conversation with me about the well known, scientifically proven ways that NSAIDS like ibuprofen, alleve, midol, and aspirin damage kidneys.

Here is the science: The kidneys receive about 25% of the blood flow from the heart, and filter blood through their delicate & intricate filter and tube mechanisms.

 It is prostaglandins that increase pain and inflammation. All NSAID medications work by inhibiting the cyclooxygenase (COX) enzyme, thus decreasing prostaglandin synthesis.However, ibuprofen and all NSAIDs also interfere with the body’s natural blood vessel constriction and dilation hormones through this system, ultimately affecting the kidneys. In the long term, this damages the delicate kidney structures from irregular blood flow. It can also lead to chronic high blood pressure.

To make matters worse, there is a second way that ibuprofen, aspirin and other NSAIDs damage the kidneys. The immune system can react against these drugs and cause an inflammatory reaction right in the matrix of the kidneys. This is called Acute Interstitial Nephritis and can happen after only one week of use. It can also become a chronic, simmering problem that is definitely underdiagnosed.

So, what to do? We cant use opioid pain medication like we used to because it is extremely addicting, and now ibuprofen, aspirin and products like Motrin or Alleve are also harmful. Sadly, acetaminophen, or Tylenol is a centrally acting medication with little anti-inflammatory action and it doesn’t work well for most pain although it is great for fever.

First of all, I would argue we as a culture need to become a little more tolerant to living with some discomfort. Pain is often a sign that something else needs to be addressed: like, hydration, nutrition, posture, or drug/alcohol overuse.

Second, the practice of prevention goes a long way to decreasing the duration and quantity of pain medications needed. WE ARE LAZY!! Simple stretching and at-home exercises can do wonders for back and body pain as can weekly yoga. People who don’t know basic stretches can be referred to physical therapy for individual assessment; this is covered by most private and federal insurances. The newest guidelines from the American Academy of Family Physicians recommend:

“Nonpharmacologic treatment, including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, biofeedback, low-level laser therapy, cognitive behavioral therapy, or spinal manipulation, should be used initially for most patients who have chronic low back pain.”

Finally, botanical medicine has an evidenced role in combating pain. Most herbs are better used proactively for prevention of pain and inflammation than acutely when symptoms are already present. Turmeric, ginger, black pepper and boswellia all have a long history of use for muscle and joint issues. New Chapter has a herbal Zyflammend product line that specifically addresses pain and/or age-related joint disease that is worth trying. Take as directed on the label, 2 tabs daily for at least 6 weeks to assess your response.

DLPA is a less used supplement for chronic pain and depression. This is DL-phenylalanine, an amino acid that gets converted into tyrosine. Rather than directly addressing pain, DLPA slows endorphin breakdown by decreasing enzymatic function. This results in higher endorphin levels for pain control as well as increased adrenal hormones such as norepinephrine. The dosage varies from 1500mg on an empty stomach each morning to 200mg twice daily. For gynecological pain like mine, cramp bark is another option. This needs to be taken in moderately high doses (3 caps 2-3 times per day)  just before menstrual pains begin, and continued throughout the pain window.

These are all good options for all kinds of pain, not just back pain. If we as a consumers were willing to put the same effort into treating & preventing our various pains proactively instead of just popping 3 Advil every 4 hours, we may live longer and healthier. The effect on the kidney is also real, and needs to be talked about more. I see patients dying of kidney failure in the hospital every day, and it is not pretty. I know that I am forcing myself to be more tolerant of the low grade pains I live with, and I just started using herbs (Vitanica’s cramp bark) and (walking and stretching) exercises in an attempt to minimize the pain medications I may really need in a few days. I am hoping it makes a difference, because my kidneys aren’t really up for another 10 years of this.

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