Todd P. Stitik, MD, professor of physical medicine and rehabilitation at New Jersey Medical School
Is Arthritis Inevitable?
by Maryann Brinley
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The prescriptions that Todd P. Stitik, MD, writes for the snap, crackle, pops and pain associated with the cumulative musculoskeletal wear and tear of 40 plus years of living -such creaking is called "crepitus," as in the word "decrepit" - aren't necessarily filled by pharmacists.
ven though millions of baby boomers might wish for a magic pill to alleviate their stiff, aching backs, necks, shoulders, hips, knees, elbows, wrists and hands, this professor of physical medicine and rehabilitation at UMDNJ-New Jersey Medical School (NJMS) is likely to recommend exercise too. And if you stand at the doorway to the Division of Physical Therapy down the hall from his office, you’ll even see from 70 to 100 patients arrive daily with prescription slips in hand ready for their supervised workouts. These sessions are only in addition to what they are supposed to be doing on their own.
“One of the reasons I chose the field of physical medicine and rehabilitation is the heavy emphasis it places on exercise as a treatment for musculoskeletal problems so I’m really enthusiastic about this approach,” Stitik says. Pain relievers, joint lubricating injections and oral supplements like glucosamine and chondroitin sulfate can be helpful in alleviating symptoms of osteoarthritis but if there is a preventative antidote to joints crackling and crumbling, it is not an easy pill or instant potion but a regular therapeutic program with lots of aerobic exercise and muscle strengthening. A balanced diet and a daily multivitamin are also on Stitik’s list of recommendations.
What we’re learning is that osteoarthritis (OA), a degenerative condition of the synovial joints and the most common form of arthritis, is a complex disease with both biomechanical and biochemical roots. Associated with age, obesity and inactivity, it can also be caused by previous trauma, infection, crystal deposits in the joints, underlying endocrine disorders such as acromegaly (a disease characterized by overproduction of growth hormones), inherited metabolic disorders or defective genes. The last “silent” generation may have taken these painful licks peacefully. Not baby-boomers. “You can’t avoid all the aches and creaks of middle age but you can reduce your risk factors for developing severe osteoarthritis and delay symptoms by exercising. This is always one of the bullet points in my treatment programs.” Director of outpatient musculoskeletal/occupational medicine at UMDNJ-University Hospital, Stitik considers osteoarthritis his primary clinical and research interest.
What’s happening in OA is that the cartilage coating the ends of bones is breaking down. “You’ll feel pain when bone rubs against exposed bone. There are nerve endings there.” Affected cartilage initially develops small tears. Synovial fluid provides nutrients and absorbs shock during movement but osteoarthritic joints have less fluid and larger tears. Over-using or abusing joints will also hasten degeneration. Thirty plus years of marathon running, for instance, can certainly strain someone’s knees. Medications, especially pain relievers, surgical interventions, arthroscopic joint washing, fusion, and artificial joint replacement are options some baby boomers know well.
“Prevention of osteoarthritis has been a controversial topic,” according to Stitik. Perhaps it took the might of millions of pushy baby boomers to cast OA in a preventable light, and not just a fact of physical life with limited treatment options. Since a National Institutes of Health (NIH) conference in 2000, a consortium of health agencies has been promoting the National Arthritis Action Plan: A Public Health Strategy to reduce OA disabilities.
Research shows that strengthening key
muscle groups, like the quadriceps, can be particularly effective. The “quads” are four muscles which run along the front of the thigh sharing a tendon that encloses the kneecap and attaches to the top of the shin in the lower leg. You need your quads to move and just a relatively minor increase in strength can produce a 20 to 30 percent decrease in your likelihood of developing
arthritic, painful knees. Simple isometric moves as well as wall slides will tone quads. Stand with your feet shoulder width apart, lean back against a wall and place your feet out in front of you as far as you comfortably can. Bend at your knees, put your hands on your waist and slide down while maintaining contact along your spine as you shift down along the wall to a point not exceeding a 90 degree bend in your knees. Slide back up slowly and repeat eight to 10 times. Stitik incorporated research on quadricep strengthening exercises into a clinical trial of exercise combined with knee injections using sodium hyaluronate (Hylagan®). He wanted to see if the combination of this FDA approved synovial fluid supplement and exercise would be more effective at relieving pain than the Hylagan alone. “Although the injections definitely helped, the group that exercised in addition to receiving injections did the best.
“As a generation, baby boomers are more exercise-oriented and that’s good. However, with more exercise, comes more injury.” Boomeritis is actually the new word for the escalating number of sports-related injuries. Trying to do too much, too quickly, or only on weekends, will result in tendonitis, pinched nerves, pulled muscles, torn cartilage, back strains, slipped disks, acute neck pain or even more serious conditions. Stitik has seen it all. “Ideally if you exercise under a doctor’s supervision, you won’t get injured. But keep in mind that the benefits of regular therapeutic exercise will still always outweigh the possibility of injury.”
Stitik incorporates range of motion and flexibility, stretching, strengthening and aerobic conditioning exercises in his programs for patients with sports injuries, work-related symptoms and other problems. His electrodiagnostic laboratory offers evaluations using the most advanced computerized technology for a wide range of acute and chronic musculoskeletal problems, including everything from pinched nerves, carpal tunnel syndrome and neuromuscular disorders. The department also treats patients with spinal cord injury, stroke, head trauma, and amputations.
Stitik, a baby-boomer himself at 44, usually exercises aerobically five times a week, playing basketball, running outside or on a treadmill, using a stair-stepper, or biking and strengthens by lifting weights in his home gym. “As you age, you tend to put on weight, which is tough on the joints,” he explains. “Every step you take is harder on your knees and hips when you are carrying extra pounds. You can also lose muscle mass. When you lose muscle, you lose strength and the muscular support joints need to move. Joints also tend to stiffen when you are inactive,” Stitik says. “Maybe this is nature’s way of getting us to move regularly.” Though he tries not to badger patients, “I bring them back for follow-up visits and they really do have to answer to me about their exercise habits. I also demonstrate and make corrections to what they may be doing wrong right here in the office.”
Staying motivated enough to stick to a regular exercise routine — a real stumbling block for many patients — is not a problem for Stitik. In fact, he admits, “I worked from home on a new book project the past few days. In between writing sessions, I was able to run in the mornings and lift weights in the afternoons. Now that I’m back in the office for a long day to see lots of patients, I know I’m going to miss and crave all that exercise.”
Cynthia Paige, MD, assistant professor of family medicine at New Jersey Medical School
What About Acupuncture?
The lights are dim in the small exam room in the Doctors Office Center on the Newark campus.
That strange scent is not from formaldehyde or anything medicinal but some sweet incense. On a counter, which should simply hold tools and charts, there is a small floral arrangement and a candle. Obviously, the stage is set for something quite different from an ordinary doctor’s appointment. In fact, the patient is a baby boomer who understands the power of acupuncture. She’s so relaxed that it becomes clear immediately that this is not her first experience being pricked and tweaked by her MD. Though points all over her body will soon be lightly penetrated with thin, solid, metallic needles, the treatment is so soothing that she will not even care about being center stage with two photographers and a reporter inches away. What matters to her most is that it works.
Three times a week — on Monday evenings, Thursday afternoons and Saturdays — Cynthia Paige, MD, an NJMS assistant professor of family medicine, devotes her busy practice to acupuncture. “For me, this is a passion and I’m really enjoying this pendulum swing.” What Paige and a growing number of ailing boomers know is that there is nothing comparable to the use of this ancient art for a variety of disorders — for everything from irritable bowel syndrome, allergies, sinusitis, infertility and nausea to headaches — but especially for pain relief.
We caught ourselves under Paige’s soft-spoken, confident spell on a typical Thursday because we were thinking tennis elbow, crackling knees, bursitis, osteoarthritic joints, low back pain, neck aches, carpal tunnel syndrome and other musculoskeletal complaints but soon found that almost any kind of pain, including the post-operative kind, can be eased or erased with acupuncture.
“It works beautifully,” not usually with a single treatment but in a series. “Everyone is different. As a family practitioner, my focus is always on preventing disease so I wanted to have every tool possible.” Offering acupuncture was a way for this doctor to provide another alternative, especially in situations where treatment is limited. A 1989 NJMS alum, Paige recently completed three years of additional study in this 2,500-year-old Eastern medical art, traveling to China as well as Japan to complete her certification. However, she’s been teaching alternative therapies in the medical school since joining the faculty 14 years ago.
She jumped at the chance to get this formal training and could have done just the minimum work which is a 300 hour course here in New Jersey to become licensed. But, she says, “I really wanted to understand the medicine not only to practice it, but to teach it, too,” so she took the long route to realizing her dream. NJMS med students and interns regularly experience her expertise and soon residents will be exposed to this complex, somewhat mysterious medicine. “I am constantly amazed and intrigued by the interface between a science that is thousands of years old and one that is still in a discovery phase.” Paige believes that knowledge of this older form of healthcare has created a paradigm shift for all of today’s researchers, patients and clinicians. Her goal is to have residents spend at least one month of rotation in complementary and alternative medicine (CAM) and a curriculum is being developed. In the East, the integration is so complete that Paige visited traditional hospitals there which also featured acupuncture centers.
“Our population is changing,” she explains. “Many of my patients are baby boomers who are well-educated, with disposable incomes and a keen interest in alternative therapies. Medical consumers want and need care based on our knowledge of their molecular structure but they are also clamoring for compassionate, holistic care that takes their individual natures into account.” Having grown wary of the side effects and overuse of pharmaceuticals and surgery, “They’ve done their research on the Internet before they come in and know acupuncture is effective for a lot of diseases.”
Even the National Institutes of Health (NIH) agrees. One NIH report indicated that there is more positive scientific proof available in defense of acupuncture than there may be for taking an aspirin. And the seal of approval has also come from the World Health Organization (WHO) and the U.S. Food and Drug Administration (FDA). Acupuncture is officially recommended for more than 40 conditions and has fewer injurious side effects than drugs or surgical interventions. Occurrence of adverse events in the use of acupuncture is extremely low and rarely life-threatening, according to the NIH.
“Today, there is so much more acceptance of acupuncture than when I joined the faculty 14 years ago,” Paige recalls. And solid science backed by clinical trials has been building to help explain its biological basis. “What’s interesting about acupuncture is that you can actually see quantitatively through blood tests where the treatment has had an effect on the immune system.” Used pre-operatively on surgery patients, there is a reduction in levels of cortisol, the stress hormone, so less pain medication is required. Hospitals stays are shorter, too. Paige mentions her experience with a common condition she sees in women who wake up with shoulder pain and numbness. “We needle specific points and the pain is gone. Practitioners of traditional Chinese medicine know that there is a point here on the lower leg,” she says, demonstrating on her sleepy patient, “that when pressed or needled, will help shoulder pain. The pain simply goes away. It’s really amazing. Western medicine has no explanation for how or why, but we know it’s all connected.”
One of the theories Paige teaches in first year gross anatomy classes is the link to the connective tissue covering everything on our bodies — bones, blood vessels, organs and tissues just beneath the skin. “By putting a needle here in the leg, I’m not only affecting the leg, I’m stimulating the whole body.” And by stimulating an area in chronic pain — the low back, for instance — “we can obtain relief. We compete with the nerve fibers in that area” that have been sending painful messages to the person’s brain.
Though Paige’s fingers ordinarily do the tweaking, occasionally electrical stimulation is applied using a little clip to the tip of the needle. Manipulating specific anatomical points on the body, along various physiological pathways or meridians, supposedly activates the release of chemicals in the muscles, spinal cord and brain. The general Eastern theory of acupuncture points to the patterns of natural energy flow, or Qi, in the human body essential to good health. When this flow is blocked or disrupted, disease or pain will occur. Acupuncture aims to correct the blockages or misdirected energy.
For baby boomers in pain, acupuncture may be just what the doctor orders.
Wonder-How-They-Work Drugs
Pregabalin… Tramadol… Abatacept… Enbrel (Etanercept)… Remicade… Milnacipran… Immunex… Humira… Oxybate… Micophenelate…
Rheumatologists deal with problems involving joints and associated conditions in connective tissue, but to be a truly effective practitioner calls for pharmaceutical finesse, and not just in your pronunciation. The name for this speciality comes from the Greek word rheuma, which means “that which flows like a river or stream,” a definition that makes sense when you start to see how difficult it could be to connect the serendipitous and bewildering biochemical dots in cases of fibromyalgia, rheumatoid arthritis, lupus erythematosus, scleroderma, polymyalgia rheumatica, dermatomyositis, spondyloarthropathies like ankylosing spondylitis, and Sjogren’s syndrome (the dry mouth, dry eye disease). Requiring disease-modifying antirheumatic drugs or DMARDs, these are complicated, chronic medical puzzles which can bring nothing but pain and sometimes depression to millions, many of whom are baby boomers. While these disorders can show up at other times of life, a majority of cases strike between 35 and 50.
Yet, a conversation with rheumatologist and baby boomer Stephen L. Burnstein, DO, a professor at UMDNJ-School of Osteopathic Medicine (SOM), quickly convinces you that understanding these diseases and finding a perfect pharmaceutical salve are labors of love. “I’ll be 60 this year.” He saw his first rheumatology patient back in medical school. “It was very, very interesting to me and not a lot was known back then in the late 1960s.”
Stephen L. Burnstein, DO, professor of internal medicine at the School of Osteopathic Medicine, flanked by clinic coordinators Patty Devito, (left) and Karen Mislowsky
Mysteries remain. Take the commonly seen link between fibromyalgia and depression. “There are lots of theories,” according to Burnstein. Does having fibromyalgia syndrome (FMS) with its muscle tenderness, swelling, and limitation of motion, make someone depressed or does depression bring on this mysterious musculoskeletal problem so prevalent in women during mid-life? “As with many medications, especially the ones which interfere with certain neurotransmitters in the brain like serotonin and norepinephrine, there are definite mind-body connections. When we treated patients with fibromyalgia for their depression, lo and behold, not only did their depression lift but the fibromyalgia got better too.” Sometimes the bio-pharmaceutical correlations are perfectly paradoxical. For instance, Burnstein is just starting a new trial testing why a drug that works for narcolepsy, the sleep disorder, is helping to relieve FMS symptoms.
Thirty years of clinical and research work as well as experience with more than 50 drug trials for patients with rheumatoid arthritis (RA) and FMS — nine are ongoing and he’s recruiting patients right now for others — have given this scientist a serious respect for “the very delicate chemical balancing acts in our bodies.” He says that over the years he’s witnessed the development of many excellent compounds, some of which have become “wonder drugs.” Most of his clinical investigations have centered on FMS and RA, the latter considered to be “potentially the most damaging and crippling” among all types of arthritis.
RA is an autoimmune disease where the body’s own immune system attacks itself. T-cells belong to a group of white blood cells or lymphocytes and are central players in immunity but are “somehow responsible for producing the substances that harm the joints.” One of Burnstein’s drug trials involves a drug which interferes with the production and activation of these T-cells. And, while there may be a clustering of joint problems in families, “there are no hard and fast patterns for genetic transmission,” Burnstein explains.
With no real cures available, these disorders and their symptoms can only be tamed with aggressive medical and pharmacological management. Maintaining a healthy weight, taking medication regularly, getting proper rest, keeping down stress levels and exercising aerobically are key. “It’s so important for patients to exercise not only from a physical standpoint but also for the effect on their brains. Production of neurotransmitters goes up when you exercise recreationally, on your own time, doing something pleasurable. It’s a release which will get your heart rate up and give you a natural high.”
Burnstein believes that doctors like himself should be no exception to the exercise rule of thumb. “As physicians we live under stressful conditions. We’re trying to reduce stress in our patients and that adds to our own stress.”
Aging Bone Basics
Bone is dynamic, living tissue which is constantly being biochemically and structurally remodeled. Old bone is degraded by cells called osteoclasts and absorbed by the body while new bone is being formed by osteoblasts. The process probably helps free calcium for other tissues and repair work elsewhere in the body. When the osteoclasts become more efficient at tearing down than the osteoblasts are at rebuilding, you end up with weakened, porous bone or osteoporosis, a condition affecting 10 million Americans and responsible for almost all fractures in older individuals.
This bone rebuilding cycle is completed every 10 years in healthy individuals, resulting in an entirely new skeleton, in fact. Adults are at peak bone mass by age 18 and density stays constant until about age 40, after which everyone tends to experience bone thinning unless the deterioration is interrupted. While drugs, hormone replacement therapy and pharmaceutical strategies are being proposed and tested to stem this crumbling tide, researchers studying the human genome have also found that something about the very act of exercising actually turns on genes in human skeletal muscles, promoting healthier growth of new bone tissue and producing an anti-inflammatory effect, especially in middle age. When muscles contract, RNA production in the cells speeds up. As a result, the body also uses insulin better; the heart pumps more efficiently; and, low-grade inflammation, implicated in all kinds of degenerative diseases including cancer, is reduced.