Articles

Arthritis, Osteo

Introduction

Osteoarthritis (OA), the most common form of joint disease, affects nearly 50 percent of the population older than the age of 65 and virtually everyone over the age of 75. (1) OA affects primarily the weight-bearing joints of the peripheral and axial skeleton, causing pain, limitation of motion, deformity, and progressive disability. Osteoarthritis may be described as degenerative joint disease (DJD) or hypertrophic arthritis, however these terms may not reflect that OA is not a single disorder, but a pattern of reactions or sequence of events that lead to joint injury.

It is often best described as a disorder of both mechanical and biologic events that alter the normal synthesis and degradation of articular cartilage. (2) Recent advances and knowledge concerning articular cartilage function and physiology have dispelled the traditional wear-and-tear theory as the cause of OA, focusing on biomechanical forces, as well as inflammatory, biochemical, and immunologic factors.

Generally, OA can be classified into two major categories. Primary (idiopathic) OA occurs without any previous triggering event or known cause and reflects the majority of cases. This category can be further classified into localized OA and generalized OA. Localized OA usually reflects involvement of one joint, while generalized OA indicates involvement of three or more joints. Erosive OA, yet a third category, reflects changes in the underlying bone. The secondary classification of OA is based on other known abnormalities or trauma. Metabolic or endocrine disorders and congenital factors would be included in this category. To assist in uniform reporting of rheumatic diseases, a classification scheme and criteria for OA of the hip, knee, and hand have been reported by the American College of Rheumatology. (3) These criteria include objective and subjective factors such as pain, sedimentation rate, bony changes on examination, and radiographic features consistent with osteoarthritis.

Cartilage is a metabolically active tissue that undergoes a continual internal remodeling of its extracellular matrix (ECM). Histologically, articular cartilage is 75-80 percent water by weight. The ECM is comprised of a small number of chondrocytes (less than 5 percent) and the remainder (20-25 percent) consists of three classes of molecules: collagens, large aggregates of proteoglycans or aggrecans, and noncollagenous proteins.

The chondrocytes control the synthesis and degradation of the ECM by affecting the production of collagen and proteoglycans. The collagens provide tensile strength and maintenance of tissue volume and shape. The proteoglycans (PGs) provide the "stuffing material" for the matrix. The PGs consist of a protein core and at least one or more glycosaminoglycan chains (chondroitin sulfate, keratan sulfate, and dermatan sulfate). These aggregates retain and maintain the water content of the cartilage because of their highly hydrophilic and anionic properties. This is what gives cartilage its resilience and load bearing properties.

The slow, progressive changes seen in osteoarthritis consist of an increase in water content, loss of proteoglycans, and reduction of PG aggregates in cartilage. The net result is failure of the cartilage to repair itself. (4)

Statistic

National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, 2000.

    More than 20 million people in the United States probably have the disease. Some younger people get osteoarthritis from a joint injury, but osteoarthritis most often occurs in older people. By age 65, more than half of the population has x-ray evidence of osteoarthritis in at least one joint. Since the number of older Americans is increasing, so is the number of people with osteoarthritis. Both men and women have the disease. Before age 45, more men have it, while after age 45 osteoarthritis is more common in women.

Signs and Symptoms

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The severity of symptoms depends upon the duration of disease, joints affected, and severity of joint involvement. Joints most commonly affected in primary OA are the distal and proximal interphalangeal joints of the hand (DIP and PIP), the first carpometacarpal joint, knees, hips, cervical and lumbar spine, and the first metatarsophalangeal joint of the toe. Patients often complain of as sense of weakness or instability, and a decreased range of motion of involved joints. Joint enlargement is typically related to bony proliferation or thickening of the synovium and joint capsule. Joint deformity may be present in later stages.

General

    Pain,deep aching Pain on motion Early in disease,pain with use Late in disease,pain at rest Stiffness in joints, limited joint motion Instability of weight bearing joints Crackling, crepitus

Treatment Options

Conventional

The primary treatment goal is to reduce pain, maintain function, and prevent further joint destruction. In general, an individualized approach consisting of non-drug therapy such as rest/exercise regimens and drug therapy can achieve these goals:

    These may include physical therapy to improve range of motion, and muscle strengthening exercises. For the overweight patient, dietary counseling is important. Excess weight can contribute not only to progression of the disease, but also to the contraction of the muscles that span and stabilize the joint. Drug therapy is directed at pain relief and inflammation when present. Acetaminophen in doses of 325 to 650mg, four times daily is recommended with a maximum dose of 4grams per day. Aspirin may be considered, but has most often been replaced by non-steroidal anti-inflammatory drugs (NSAIDs). NSAID choice is frequently a matter of prescriber preference based on past treatment, cost, patient preference, toxic effects, and compliance. In general, NSAIDs are used after simple analgesics have failed, or if inflammation is present. A new class of NSAIDs has been designed to avoid the stomach and intestinal problems commonly associated with "traditional" NSAIDs. These drugs are known as COX-2 Inhibitors and are available with a prescription, they include celecoxib, rofecoxib, and valdecoxib. Hyaluronate injections: recently, new intra-articular injections have become available for treatment of pain associated with OA of the knee (sodium hyaluronate). They are intended to assist in the reconstitution of synovial fluid, thereby improving joint function. Hyaluronic acid also plays a role in cartilage matrix formation through aggregation with proteoglycanen. Several published studies have indicated benefit with this therapy. (5) , (6) , (7)

Nutritional Supplementation


Glucosamine

Glucosamine is naturally synthesized by chondrocytes (cartilage cells). In osteoarthritis, this synthesis is either insufficient or defective, and supplementation with glucosamine has proven to be useful. The body apparently uses supplemental glucosamine to synthesize proteoglycans and the glycosaminoglycans (GAGs) in the cartilage matrix. However, this mechanism of action does not explain the rapid symptomatic relief that some patients experience with glucosamine therapy. An alternative or additional possibility is that glucosamine stimulates synovial production of hyaluronic acid, which is primarily responsible for the lubricating and shock-absorbing properties of synovial fluid. (8)

Results of most studies with glucosamine in the treatment of osteoarthritis indicate that it is effective in decreasing pain and improving joint function. (9) This chondroprotective agent has been reported to reverse or at least stop the progression of the disease without inducing serious adverse effects. A 3-year study involving 202 people with mild to moderate knee osteoarthritis were randomized to either 1500mg/day of glucosamine sulfate or placebo. There was no average change in progressive joint space narrowing in the glucosamine group which significantly differed from the change noted in the placebo group. Glucosamine sulfate also significantly improved symptoms compared to placebo. The researchers felt as though the retardation noted in several measures of disease progression could possibly indicate disease modification. (10)

Also, limited data from short-term human trials suggest that glucosamine sulfate administered orally, intravenously, intramuscularly, and intra-articularly may produce a gradual and progressive reduction in joint pain and tenderness, as well as improved range of motion and walking speed. Results of the trials have also reported that glucosamine has produced consistent benefits, with greater than 50 percent overall improvement in symptom scores, in patients with OA, and that in some cases, it may be equal or superior to ibuprofen in controlling symptoms, with far fewer side effects. (11) , (12) It may take three to four weeks before glucosamine is effective, so stronger anti-inflammatory medication may be necessary for acute conditions for a short period of time.


Chondroitin Sulfate

Chondroitin sulfate is one of the primary structural components of cartilage. It is a very large molecule composed of repeating units of glucosamine sulfate. Glucosamine and chondroitin sulfate both attract water into the cartilage matrix and stimulate the synthesis of cartilage. It has the ability to prevent enzymes from dissolving cartilage. (13) Thus, chondroitin helps prevent deterioration and also supplies the body’s needs for the primary materials needed to repair and rebuild degenerating joints.

Results of a double-blind study with chondroitin 4- and 6- sulfate (800mg/day), indicated that therapy was effective in reducing joint pain and increasing overall mobility. (14) In a three-year double-blind study, 119 patients with finger-joint osteoarthritis taking chondroitin (400mg, three times daily) had much less progression of the disease compared to placebo patients. (15) In osteoarthritis of the knee, 80 patients in a six-month double-blind study took chondroitin (400mg twice daily) or a placebo. The chondroitin demonstrated significant improvements in walking time compared to placebo controls and a significant reduction in the consumption of pain-killing drugs. Excellent tolerability was also observed. (16)


S-Adenosylmethionine (SAMe)

Results of studies indicate that SAMe may be as effective as ibuprofen, (17) indomethacin (18) and celecoxib (19) in the treatment of OA. Experimental evidence from multiple clinical trials reveals that the administration of SAMe exerts analgesic and anti-inflammatory activities and stimulates the synthesis of proteoglycans by articular chondrocytes with no significant side effects on the gastrointestinal tract and other organs. (20)

In a two-year multicenter open trial, SAMe was administered to 108 patients with osteoarthritis of the knee, hip, and spine. Ninety seven patients completed the trial. The dose was 600mg daily for the first two weeks and then 400mg daily thereafter. The improvement of the clinical symptoms including morning stiffness, pain at rest, and pain on movement became evident after the first few weeks of treatment and continued up to the end of the 24th month. In this trial, SAMe was well tolerated and also improved the depressive feelings that are often associated with osteoarthritis. (21)


Methyl Sulfonyl Methane (MSM)

Clinical observations from pioneering researchers have reported that methyl sulfonyl methane (MSM) has reduced or eliminated the pain for many patients with osteoarthritis. (22) Since clinical trials have not yet been conducted, these early reports cannot be substantiated.


Vitamin C

A correlation between OA and the antioxidant nature of vitamin C was evaluated in the Framingham Osteoarthritis Cohort Study. Evidence from this study revealed that individuals in the middle and highest tertile of vitamin C intake exhibited a 3-fold reduced risk of disease progression in people with OA. This risk reduction was related to reduced risk of cartilage loss and reduced risk of developing knee pain in individuals with high vitamin C intake. High intake of vitamin C did not reduce the incidence of osteoarthritis and further confirmation of these findings is necessary. (23)

A preliminary study found that higher intakes of vitamin C may reduce the risk of inflammatory polyarthritis. The results showed that there was an increased risk of polyarthritis in those with lower dietary intakes of fruits and vegetables, and vitamin C. (24)


Vitamin E

A three-week double blind study evaluated the efficacy of vitamin E compared to diclofenac in patients with osteoarthritis of the hip or knee. Both treatments appeared to be equally effective in reducing the circumference of the knee joints, walking time and in increasing the joint mobility in patients. (25) Side effects occurred in 7.7 percent of patients taking vitamin E compared to 25.9 percent of patients taking diclofenac.


Vitamin B3

It has been suggested that niacinamide functions by inhibiting the induction of nitric oxide synthase, which reduces the production of interleukin-1 (IL-1). Interleukin-1 is a proinflammatory cytokine, which is capable of inhibiting the synthesis of type 2 collagen. (26)

Initial reports about niacinamide’s usefulness in the treatment of osteoarthritis began appearing in the scientific literature in the 1950's. (27) , (28) , (29) Now, a more recent study verifies these earlier observations suggesting that niacinamide can play a beneficial role in the treatment of osteoarthritis. This was a randomized double-blind, placebo-controlled 12-week trial with 72 OA patients. The global arthritis impact improved by 29 percent in patients taking niacinamide. The same measure worsened by 10 percent in placebo subjects. Pain levels did not change, but those using niacinamide reduced their anti-inflammatory medications by 13 percent. Niacinamide reduced erythrocyte sedimentation rate by 22 percent and increased joint mobility by 4.5 degrees over controls (8 degrees vs 3.5 degrees). Side effects were mild, but higher in the niacinamide group (40 percent vs 27 percent). (30) If there is any nausea or gastric distress, stop briefly, reduce the dosage, and resume. Liver enzymes should be monitored periodically.


Boron

Data from numerous areas of investigation indicate that boron is an essential nutrient for healthy bones and joints, and that it may have a role to play in the treatment of osteoarthritis. These preliminary observations include the following: analytical evidence revealed lower boron concentrations in femur heads, bones, and synovial fluid from people with osteoarthritis than from those without this disorder. It has been observed that bones of patients using boron supplements are much harder to cut compared to the bones of patients not taking a boron supplement. Epidemiological evidence reveals that in areas of the world where boron intakes usually are 1mg or less/day, the estimated incidence of arthritis ranges from 20 to 70 percent; whereas in areas of the world where boron intakes are usually 3 to 10mg, the estimated incidence of arthritis ranges from 0 to 10 percent. In laboratory experiments, rats with induced arthritis benefit from orally or intraperitoneally administered boron. In addition, a double-blind placebo-controlled trial with a small sample size of 20 subjects with osteoarthritis, demonstrated a favorable response to a 6mg boron/day supplement. Half of the subjects among this small sample size receiving boron supplementation improved compared to only a tenth of those receiving the placebo. (31)

Herbal Supplementation


Boswellia

Boswellia, or Olibanum, is a close relative of the Biblical incense frankincense, and has been used historically in the Ayurvedic medical system of India for arthritis, dysentery, liver diseases, obesity, neurological disorders, ringworm, boils, and other afflictions. (32) Boswellia is a gum resin extract from the stem bark of the Boswellia serrata tree. It is emerging as an agent for the management of symptoms associated with arthritis. (33)

Animal studies performed in India reported that ingesting an extract of boswellia had decreased polymorphonuclear leukocyte infiltration and migration, decreased primary antibody synthesis, and the agent caused almost total inhibition of the classical complement pathway. (34) An in vitro study of the isolated chemical constituent b-boswellic acid on the complement system reported a marked inhibitory effect on both the classical and alternate complement systems. (35)

Boswellia’s anti-inflammatory activity seems to be produced by blocking the synthesis of 5-lipoxygenase products, including 5-hydroxyeicosatetraenoic acid (5-HETE) and leukotriene B4 (LTB4). (36) , (37) It is known that NSAIDs can cause a breakdown of glycosaminoglycan synthesis, which can speed up the articular damage in arthritic conditions. (38) Boswellia was reported to significantly reduce the degradation of glycosaminoglycans compared to controls, whereas the NSAID ketoprofen was reported to cause a reduction in total tissue glycosaminoglycan content. (39)


Grape Seed Extract

Proanthocyanidins (PCOs), the active constituent in grape seed, is a flavonoid-rich compound with free radical scavenging activity. It has been reported to enhance the absorption of and work synergistically with vitamin C. (40) PCOs have been reported to inhibit the release of mediators of inflammation, such as histamine and prostaglandins. (41) , (42) Though activity has not been demonstrated in human clinical trials, rat and mouse inflammation models have demonstrated an inflammatory effect of a proanthocyanidin extract. (43) As antioxidants, proanthocyanidins are reported to neutralize free radicals, including hydroxyl, lipid peroxides, and iron-induced lipid peroxidation as well as inhibiting the formation of inflammatory cytokines. (44) , (45) , (46) They may also inhibit the enzyme xanthine oxidase.


Ginger

Ginger has been used throughout history as both a culinary herb and a medicinal agent. The volatile oils in ginger are thought to act as peripheral vasodilators or circulatory stimulants. (47) Gingerol, an identified active constituent, stimulates gastric secretions and peristalsis. (48) Ginger’s structural phenols are similar to aspirin and may have an effect on prostaglandins, PGE2 and PGF2, as well as thromboxane, leading to its use as an anticoagulant. (49)

Ginger has reported anti-inflammatory properties and has been used in some inflammatory conditions such as arthritis. (50) Ginger was reported to be effective against pain and swelling in more than three-quarters of the 56 patients involved in a clinical study (28 with rheumatoid arthritis, 18 with osteoarthritis and 10 with muscular discomfort). (51) None of the patients reported adverse effects during the period of ginger consumption which ranged from 3 months to 2.5 years.

Two-hundred and forty seven patients completed a study lasting 6-weeks evaluating the safety and efficacy of ginger in osteoarthritis (OA) of the knee. The ginger extract group had greater response in the primary endpoint of reduced knee pain upon standing as well as all the secondary endpoints evaluated. Less rescue medication (acetaminophen) was used by the ginger group, who experienced more gastrointestinal adverse effects, most of them mild. It is important to note that the change in the quality of life was equal between the ginger and placebo group. (52) Not all results are as supportive of ginger's use for inflammation. Another study found no significant advantage of using ginger root over conventional anti-inflammatory agents such as ibuprofen. (53)


Cat's Claw

Cat’s claw has been used as a traditional medicine among the people of Peru and surrounding countries possibly dating back as far as the Incan civilization. Cat’s claw reportedly affects the immune system and acts as a free radical scavenger. (54) Cat’s claw contains glycosides, which reportedly reduce inflammation and edema. (55) The anti-inflammatory effects of cat’s claw are considered to be due to the sum total of the plant’s constituents, but more recent research has shown that the sterols have demonstrated anti-inflammatory activity in animal studies. Though mechanistic support for anti-inflammatory activity exists, human data is lacking. (56) One human trial evaluated the effect of cat's claw on individuals with osteoarthritis of the knee and found it to be more effective in the 30 individual's using cat's claw than in the 15 placebo controls. (57)


Turmeric

In Ayurvedic medicine, turmeric rhizome has been used for centuries internally as a tonic for the stomach and liver and as a blood purifier, and externally in the treatment and prevention of skin diseases and in arthritic complaints. (58) Laboratory and clinical research indicates that turmeric and its phenolics have unique antioxidant and anti-inflammatory properties. (59) , (60) Some preliminary research indicated that the anti-inflammatory strength of turmeric was comparable to drugs such as indomethacin. (61) Turmeric has been reported to have anti-rheumatic, anti-inflammatory, and antioxidant activity. (62) Curcuminoids, a group of identified active constituents, reportedly inhibit enzymes which participate in the synthesis of inflammatory substances (leukotrienes and prostaglandins) derived from arachidonic acid. Studies have demonstrated activity comparable to NSAIDs. (63) In a double-blind study of individuals with rheumatoid arthritis, curcumin produced significant improvement in all subjects. (64) Of concern is the small sample size and the lack of a placebo control in this study.

Curcumin reportedly has a similar action to that of aspirin and aspirin-like anti-inflammatory agents. (65) However, an advantage of curcumin over aspirin is claimed, since curcumin, unlike aspirin, is reported to selectively inhibit synthesis of inflammatory prostaglandins but does not affect the synthesis of prostacyclin. (66) Curcumin may be preferable for individuals who are prone to vascular thrombosis and require anti-inflammatory and/or anti-arthritic therapy.

Homeopathic

Arnica montana

Typical Dosage: 6X or 6C,30X or 30CPain and inflammation; Joints feel bruised; Pain in back and shoulders, worse with movement

Bryonia alba

Typical Dosage: 6X or 6C, 30X or 30CJoints are swollen, red, and hot; Every muscle aches; Pain in back and limbs, slightest movement aggravates

Calcarea phosphorica

Typical Dosage: 6X or 6C, 30X or 30CJoints feel cold; Pain and stiffness worse with change in weather; Pain in shoulders and arms; Weakness climbing stairs

Dulcamara

Typical Dosage: 6X or 6C, 30X or 30CJoint pain when weather is humid, somewhat better from motion

Rhus toxicodendron

Typical Dosage: 6X or 6C, 30X or 30CJoint stiffness especially in the morning, better by walking and moving around; Pain relieved by heat but aggravated by cold and dampness

Acupuncture & Acupressure

Yang Wen He combined acupuncture with herbal formula for 47 patients. The herbal formula he used contained Shou Di (Rehmannia), Shan Zhu Yu (Cornus), Shan Yao (Dioscorea), Fu Ling (Hoelen), Niu Xi (Achyranthes), Chi Shao (Peony Red), Dang Gui (Dang Gui), Huang Qi (Astragalus Root), Mu Dan Pi (Moutan), and Ze Xie (Alisma). The acupuncture points used were E Shi, Wei Zhong (B40), Wei Yang (B39), and Chen Shan (B57). Also trigger points along the spine were used. After one to three treatment units, 11 patients received clinical recovery (23.4%). 24 cases received substantial progress (51.1%). 8 patients received progress (17.0%). 4 cases showed no response (8.5%). The effectiveness rate for this group was (95.1%). (67)

Du Chang Hua chose aauriculoacupuncture for 30 patients. After two treatment units, all patients received satisfactory results. (68)

Song Ya Guang conducted a clinical trial on 120 patients with a combination of cupping and blood-letting therapy. After five treatment-units, there was a 93% effectiveness rate. (69)

Massage and Other Treatments
Li Jian Jun treated 34 patients with a combination of massage and herbal penetration technique. He used four different types of massage therapy to the affected area. He boiled eleven different kinds of herbs into herbal syrup. He applied the herbal syrup to the affected areas of knee joints, and the herbal penetration technique was used to enhance penetration in these areas for twenty minutes a day, with ten times as one treatment unit. After three units, there was an effectiveness rate of 88.2%. (70)

Yao Rong Zhong combined massage and herbal bath therapy for 38 patients. The patients received twenty minutes of massage for three times a week and had herbal baths for twenty minutes twice a day. After three weeks, there was a 74% effectiveness rate. (71)

Huang Yong Ping used medicinal food for this condition. The food he suggested includes antler wine, eel cooked in Ren Sheng (Ginseng) and Dang Gui (Dang Gui), wine processed with Dang Gui (Dang Gui), Hong Hua (Carthamus), and Bai Shao (White Peony Root), pork rib stew, meat, eggs, and milk. (72)

Traditional Chinese Medicine

Arthritis, Osteo

Extensive information regarding the treatment of this health condition using Traditional Chinese Medicine is available through the link above.

Diet & Lifestyle

    Identify and eliminate food and/or environmental allergies; especially consider the nightshade food group (potato, eggplant, bell pepper). Weight control; excess weight increases compression on joint cartilage. Water; maximal hydration is imperative since the glycosaminoglycans in the cartilage matrix bind and hold water, which acts like a shock absorber.

Clinical Lab Assessment

Some of the following laboratory testing can provide information necessary for the diagnosis and treatment of osteoarthritis. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.

Fatty Acids

Dietary polyunsaturated fatty acids (PUFA) are primarily composed of omega-3 and omega-6 fatty acids. PUFA are vital in the production of eicosanoids which are components involved in regulating inflammatory response.

Clinical Notes

Deer antler velvet, which is the soft cartilaginous tissue from red deer or elk (Cervus species), is rich in the structural and nutritional components of cartilage. It contains substantial quantities of glycosaminoglycans (GAGs) such as glucosamine and chondroitin sulfate, as well as keratin sulfate, hyaluronic acid, dermatan sulfate, and decorin. (73) Although a wealth of anecdotal reports and clinical observations claim that deer antler velvet products provide benefits to patients with osteoarthritis, well-designed clinical trials are lacking. However, three separate studies evaluating these claims are underway. Though data is limited, deer antler velvet products are thus far considered safe and without side effects. The dosage varies according to the type of product that is used.

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