Dr. James Manos (MD)
July 5, 2019
July 5, 2019
Natural treatments for arthritis
Orthopedic products with Nanotechnology using infrared (IR) rays & bio-magnets
Herbs & dietary supplements for arthritis (and especially for osteoarthritis) analytically.
(osteoarthritis treatments usually have studied only on knee osteoarthritis, but in some cases, they have been studied in other joints such as the hip and temporomandibular joint (TMJ))
(with green color are the herbs & dietary supplements that I personally consider more important for this issue):
· You may purchase herbs & dietary supplements on several sites on the internet, such as www.iherb.com
· On arthritis, and especially on knee osteoarthritis, glucosamine sulfate (e.g., from shells or crabs as sources), chondroitin sulfate, and MSM (a sulfur product) may help. Caution is needed as glucosamine & chondroitin may increase bleeding diathesis (tendency) in people taking blood thinners such as warfarin, and thus, they are contraindicated in these patients. Their combination may have synergistic effects on the above adverse effect. Chondroitin is considered a relative of heparin, a blood thinner.
· Celadrine™ (cetylated fatty acids)
· Hydrolyzed collagen (a very cheap way to eat collagen, as gelatin is made from the bones, skin & other tissues of beef and other animals, is to eat the delicious dessert ‘jelly’ that often contains fruits and has fruit taste that you can purchase as a desert on the supermarket or on powder to make it yourself – jelly referred here should not be confused with jelly candies and also it should not be confused with the jelly made from pectin and sweetened fruit or vegetable juice, as in the USA & Canada, or the redcurrant or blackcurrant jelly and other fruit jellies with pectin in the UK)
· Arthred™ is a patented form of collagen, originally developed in Germany from bovine cartilage. It is considered a functional food, as it contains 19 amino acids.
· Hyaluronic acid
· Curcumin (turmeric) (nano curcuminoids and Meriva™, as well as Longvida™, are better absorbed)
· Boswellia serrata (Frankincense) (however, it contains boswellic acids and other substances that may harm the liver if taken in high – doses for a long time; thus, they are contraindicated on people with liver problems, fatty liver, and alcohol abuse; however, studies showed that this herb may protect the liver from damage from toxins)
· Devil’s claw (this is also a painkiller; it should also not be taken by people on blood thinners)
· Ginger
· Tart cherry (an excellent antioxidant, rich in anthocyanins & flavonoids)
· Bromelain (a peptic (that helps with digestion) enzyme contained in pineapple)
· Black pepper (however, it should be consumed in moderate amounts as it contains safrole, a carcinogen!)
· Omega 3 fatty acids (EPA & DHA) from fish oil.
· SAMe (S-adenosylmethionine) (it is a bit expensive; it may also help people with depression! A theoretical adverse effect is that perhaps in the long term, it may cause Parkinson–like syndrome. However, this has not been studied or observed in humans, and it is just a theoretical concern that needs further investigation).
Joint creams/gels/ointments for arthritis
· Arnica montana (a herb that helps patients with sprains, strains, muscle, tendon & ligament injuries, and muscle pain from exercise).
· Glucosamine sulfate (e.g., from shells or crabs as sources), chondroitin sulfate (it is like the blood–thinner heparin!), and MSM (a sulfur product).
· Celadrine™ (cetylated fatty acids)
· Boswellia serrata
· Devil’s claw (this is also a painkiller with substantial analgesic effects).
· Herbal joint creams may be combined with pharmaceutical ointments/ creams such as NSAIDs (non–steroidal anti-inflammatory drugs), diclofenac, and naproxen (e.g., Naprosyn™ 10%) cream.
Energy (power) (magnetic) bracelets!
These ‘power bracelets’ are sold by several manufacturers. They use magnetic or other low–frequency energy. Some are from titanium, and the companies allege that it may help with balance and enhance power. However, there is no scientific proof that they really work. Also, potential adverse effects from the low-energy electromagnetic power have not been studied, so long-term safety is unclear. Another issue is that their exact mechanism of action is unknown, and a variety of products show diversity in this ‘technology.’ You may check https://en.wikipedia.org/wiki/Power_Balance
Magnetic fields have been used in physical therapy for decades. IR (infrared) beams cause a mild warming effect on the affected area, such as joints. Someone can purchase a commercial product (‘wrap’ or cloth) covering a joint such as knee, elbow, or shoulder, with an IR internal lining and magnets for, e.g., 1 hour, and may increase the warming sensation by using a joint warming cream in combination with an NSAID cream and Arnica (an herb) cream, 10 minutes before wearing it.
· beta-carotene
· Boswellia serrata/ boswellic acids
The results of a study where they used Boswellia serrata Extract (BSE) in 30 patients with osteoarthritis of the knee showed that all patients receiving drug treatment reported a decrease in knee pain, increased knee flexion, and increased walking distance; also, the frequency of swelling in the knee joint was decreased – the study concluded that Boswellia serrata Extract (BSE) is recommended in the patients of osteoarthritis of the knee with possible therapeutic use in other types of arthritis.
Another human study concluded that 5-Loxin, a novel Boswellia serrata extract, reduces pain and improves physical functioning significantly in osteoarthritis (OA) patients, and it is safe for human consumption; 5-Loxin may exert its beneficial effects by controlling inflammatory responses by reducing proinflammatory modulators, and it may improve joint health by reducing the enzymatic degradation of cartilage in OA patients.
Another human study concluded that Boswellia serrata extract (BSE) showed a slower onset of action in osteoarthritis (OA). Still, the effect persisted even after stopping therapy, while the activity of valdecoxib (an NSAID) became evident faster but waned rapidly after stopping the treatment.
A human study suggests that Aflapin, a novel synergistic composition derived from Boswellia serrata gum resin, conferred clinically and statistically significant improvements in pain scores and physical function scores in osteoarthritis (OA) subjects; thus, Aflapin provided substantial improvements in pain score and functional ability in as early as 5 days of treatment and is a safe, fast-acting, and effective alternative intervention in the management of osteoarthritis (OA).
· Bromelain
Bromelain has been used for the following conditions: a) Surgery, sprains & strains, and tendinitis. Although studies show mixed results, bromelain may reduce swelling, bruising, healing time, and pain following surgery and physical injuries. It often reduces inflammation associated with tendonitis, sprains and strains, and other minor muscle injuries.
A human study concluded that bromelain may be useful in ameliorating physical symptoms and improving general well-being in otherwise healthy adults suffering from mild knee pain in a dose-dependent manner.
Another human study concluded that the oral enzyme-rutosid combination (ERC) containing rutosid and the enzymes bromelain and trypsin can be considered an effective and safe alternative to NSAIDs such as diclofenac in the treatment of painful episodes of osteoarthritis (OA) of the knee.
Another human study concluded that Phlogenzym (PE; it contains bromelain, trypsin, and rutosid trihydrate) may well be recommended for the treatment of patients with osteoarthritis (OA) of the hip with signs of inflammation as indicated by a high pain level.
· Celery seed/ extracts from Indian celery seed and the NZ green-lipped mussel
· Turmeric/ curcumin (e.g., Meriva (R), a proprietary curcumin-phosphatidylcholine phytosome complex; a product with enhanced absorption)
A study that investigated Meriva's long-term efficacy and safety for eight months in 100 patients with osteoarthritis (OA) showed significant improvements in both the clinical and biochemical endpoints for Meriva compared to the control group. Also, there was excellent tolerability – the study concluded that Meriva is worth considering for the long-term complementary management of osteoarthritis.
Another human study showed that Meriva (R) is clinically useful in managing and treating osteoarthritis (OA) and suggests that the increased stability and better absorption of curcumin are induced by complexation with phospholipids.
A study concluded that the novel pharmacological actions of curcumin on advanced glycation end products (AGEs) – stimulated chondrocytes (cartilage cells) provide new suggestions that curcumin has nutritional potential as a naturally occurring anti-inflammatory agent for treating osteoarthritis (OA).
According to a review, recent work has shown that curcumin protects human chondrocytes (cartilage cells) from the catabolic actions of interleukin-1 beta (IL-1beta), including matrix metalloproteinase (MMP)-3 up-regulation, inhibition of collagen type II, and down-regulation of beta1-integrin expression. Curcumin blocks IL-1beta-induced proteoglycan degradation, AP-1/NF-kappaB signaling, chondrocyte apoptosis, and activation of caspase-3. The review concluded that the available data from published in vitro and in vivo studies suggest that curcumin may be a beneficial complementary treatment for osteoarthritis (OA) in humans and companion animals.
· Devil’s claw
Several studies have found that taking devil’s claw for 8 – 12 weeks reduces pain and improves physical functioning in people with osteoarthritis. One 4-month study of 122 people with knee and hip osteoarthritis compared devil’s claw and medication for pain relief. The people who took devil’s claw had as much pain relief as the people who took the medication, and those who took devil’s claw had fewer side effects and needed fewer pain relievers throughout the study. An analysis of 14 studies using devil’s claw to treat arthritis found that the higher quality studies showed that devil’s claw may provide relief for joint pain. Also, a review of twelve studies using devil’s claw for arthritis or low back pain found that devil’s claw was moderately effective for osteoarthritis of the spine, hip, and knee.
Taking devil’s claw alone or along with nonsteroidal anti-inflammatory drugs (NSAIDs) seems to help decrease osteoarthritis-related pain. Some evidence suggests that devil’s claw works as well as diacerein (a slow-acting drug for osteoarthritis that is not available in the U.S.) for improving osteoarthritis pain in the hip and knee after 16 weeks of treatment. Some people taking devil’s claws seem to be able to lower the NSAIDs they need for pain relief.
A review concluded that devil’s claw appears to be associated with minor risk (relative to NSAIDs) (in the treatment of osteoarthritis pain), but further long-term assessment is required.
The results of an open human clinical study suggest that this Devil's Claw extract has a clinically beneficial effect in the treatment of arthrosis (osteoarthritis) of the hip or knee – specifically, the results of the study revealed a substantial reduction of pain and the symptoms of osteoarthritis; there was a relevant improvement of each WOMAC subscale as well as of the total WOMAC index: 23.8% for the pain subscale, 22.2% for the stiffness subscale and 23.1% for the physical function subscale; the WOMAC total score was reduced by 22.9%.
· Ginger
Zingiber officinale (ginger) is used for rheumatic conditions such as osteoarthritis and rheumatoid arthritis. Ginger may have anti-inflammatory effects by inhibiting COX and lipoxygenase. It may also affect tumor necrosis factor and decrease the synthesis of inflammatory prostaglandins.
There is evidence that ginger may help reduce osteoarthritis (OA) pain. In a study of 261 people with OA of the knee, those who took a ginger extract twice daily had less pain and needed fewer pain-killing medications than those who received a placebo.
Some research shows that ginger can modestly reduce pain in some people with arthritis called ‘osteoarthritis.’ One study showed that taking a specific ginger extract (Zintona EC) 250 mg four times daily reduced arthritis pain in the knee after 3 months of treatment. Another study showed that using a different ginger extract (Eurovita Extract 77; EV ext-77), which combines ginger with Alpinia also reduces pain upon standing, pain after walking, and stiffness. Some research has compared ginger to medications such as ibuprofen. In one study, taking ginger extract 500 mg twice daily worked about as well as ibuprofen 400 mg three times daily for hip and knee pain related to arthritis. In another study, a specific ginger extract combined with glucosamine (Zinaxin glucosamine, EV ext-35) worked as well as the anti-inflammatory medication diclofenac slow release 100 mg daily plus glucosamine sulfate 1 gram daily.
A study concluded that a highly purified and standardized ginger extract had a statistically significant effect on reducing knee osteoarthritis symptoms (OA).
· Glucosamine sulfate
Results from several well-designed scientific studies suggest that glucosamine supplements may be an effective treatment for osteoarthritis (OA), particularly OA of the knee or hip. In general, these studies indicate that glucosamine: reduces OA pain, improves function in people with hip or knee OA, reduces joint swelling and stiffness, and provides relief from OA symptoms for up to 3 months after treatment is stopped. The 2006 Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT) of about 1 600 people with OA of the knee, sponsored by the National Institutes of Health, showed conflicting and somewhat confusing results. The study found that glucosamine alone or combined with chondroitin did not reduce pain in the overall group. However, it did appear to lessen pain among those with moderate to severe OA of the knee. The second phase in 2008 looked at some participants who continued the study for another 28 months. They were tested to see whether glucosamine or chondroitin (together or alone) slowed the loss of cartilage in their knees. They showed no difference in cartilage loss compared with people who took the placebo. But all groups, those taking a placebo, those taking both supplements, and those receiving only one supplement, lost less cartilage than expected.
Glucosamine is likely effective for osteoarthritis. Most research on glucosamine sulfate has measured its effectiveness on osteoarthritis of the knee. However, there is some evidence that it might also help osteoarthritis of the hip or spine. Some research suggests that glucosamine reduces the pain of osteoarthritis in the knee as well as the over-the-counter pain reliever acetaminophen (Tylenol) (paracetamol). It also seems to reduce pain about as much as the nonsteroidal anti-inflammatory drugs (NSAIDs), ibuprofen (Motrin, Advil), and piroxicam (Feldene). Glucosamine sulfate takes about 4 – 8 weeks to reduce pain. Glucosamine sulfate does not seem to decrease pain in everyone who receives it. Some people get no benefit. Some research shows that glucosamine sulfate might not work very well for people with more severe, long-standing osteoarthritis or for people who are older or heavier. In addition to relieving pain, glucosamine sulfate might also slow the breakdown of joints in people with osteoarthritis who take it long-term. Some researchers hope that glucosamine sulfate might keep osteoarthritis from getting worse as quickly as it otherwise might. There is evidence that people taking glucosamine sulfate might be less likely to need total knee replacement surgery.
A review assessed randomized controlled trials (RCTs) evaluating the effectiveness and toxicity of glucosamine in osteoarthritis (OA). 16 identified RCTs proved that glucosamine is effective and safe in OA. In the 13 RCTs in which glucosamine was compared to placebo, glucosamine was found to be superior in all RCTs except one. In the 4 RCTs in which glucosamine was compared to an NSAID, glucosamine was superior in two and equivalent in two.
A multicenter, double-blind, placebo- and celecoxib (an NSAID (non-steroidal anti-inflammatory drug)) – controlled Glucosamine/chondroitin Arthritis Intervention Trial (GAIT) evaluated the efficacy of glucosamine and chondroitin sulfate and safety as a treatment for knee pain from osteoarthritis (OA). The study concluded that glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of knee osteoarthritis patients. However, exploratory analyses suggest that the combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate-to-severe knee pain.
A meta-analysis concluded that trials of glucosamine and chondroitin preparations for osteoarthritis (OA) symptoms demonstrate moderate to significant effects. Still, quality issues and likely publication bias suggest these effects are exaggerated. Nevertheless, some degree of efficacy appears probable for these preparations.
An update of a Cochrane review concluded that pooled results from studies using a non-Rotta preparation of glucosamine or adequate allocation concealment failed to show benefit in pain and WOMAC function. In contrast, those studies evaluating the Rotta preparation of glucosamine showed that glucosamine was superior to placebo in the treatment of pain and functional impairment resulting from symptomatic osteoarthritis (OA).
A study concluded that allocation to the glucosamine-chondroitin combination resulted in a statistically significant reduction in joint space narrowing (JSN) at 2 years. While all allocation groups demonstrated reduced knee pain over the study period, none of the treatment allocation groups showed significant symptomatic benefit above placebo.
· Chondroitin sulfate
Clinical research on the effectiveness of chondroitin sulfate taken by mouth for osteoarthritis is inconsistent. The reason for contradictory findings is unclear but could be due to differences in people studied, different products used, or other variations in study design. Overall, the evidence shows that some people with osteoarthritis of the knee or hand can experience some benefit from taking chondroitin; however, pain relief is likely modest or insignificant.
Results from several well-designed scientific studies suggest that chondroitin supplements may be an effective treatment for OA, particularly OA of the knee or hip. However, one recent review of several studies found no benefit from using chondroitin alone. In general, findings from these studies suggest that chondroitin: reduces OA pain, improves the functional status of people with hip or knee OA, reduces joint swelling and stiffness, and provides relief from OA symptoms for up to 3 months after treatment is stopped. However, the largest clinical trial, the 2006 Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), sponsored by the National Institutes of Health, showed conflicting and confusing results. The study of about 1,600 people with knee OA found that glucosamine and chondroitin did not reduce pain in the overall group, although it did appear to reduce pain among those with moderate to severe knee OA. A second phase of the study in 2008 looked at some participants who continued with the research for another 28 months. They were tested to see whether glucosamine or chondroitin (together or alone) slowed the loss of cartilage in their knees. They showed no difference in cartilage loss compared with people who took the placebo. But all groups – those receiving a placebo, those taking both supplements, and those taking only one supplement – lost less cartilage than expected. Results continue to be mixed. One analysis of some studies found that smaller trials tended to find that chondroitin was effective, while more extensive, more thorough studies found that it wasn't.
A study that assessed the effect of chondroitin sulfate (CS) treatment in patients with knee osteoarthritis (OA) concluded that chondroitin sulfate (CS) treatment significantly reduced the cartilage volume loss in knee osteoarthritis (OA) starting at 6 months of treatment, and subchondral bone marrow lesions (BML) at 12 months. These findings suggest a joint structure protective effect of CS and provide new in vivo information on its mode of action in knee OA.
A meta-analysis concluded that chondroitin sulfate effectively reduces the decline in minimum joint space width in patients with knee osteoarthritis (OA).
· Glucosamine & chondroitin
A human study concluded that allocation to the glucosamine-chondroitin combination resulted in a statistically significant reduction in joint space narrowing (JSN) at 2 years; while all allocation groups demonstrated reduced knee pain over the study period, none of the treatment allocation groups showed significant symptomatic benefit above placebo.
· MSM (methylsulfonylmethane)
MSM is usually found in combination supplements containing glucosamine and/or chondroitin.
A human study concluded that patients with osteoarthritis (OA) of the knee taking MSM for 12 weeks showed an improvement in pain and physical function. These improvements, however, are small, and it is yet to be determined if they are of clinical significance.
A study on rats showed that intake of MSM for 4 weeks did not affect cartilage formation in the knee joint in growing rats. Body, liver, and spleen weights in the MSM100G group were significantly lower than in the control group. Intake of MSM for 13 weeks decreased the degeneration of the cartilage at the joint surface in the knee joints in STR/Ort mice in a dose-dependent manner. These results suggest that appropriate intake of MSM is possibly effective in OA model mice; however, consumption of large amounts of MSM induced the atrophy of several organs.
One preliminary study suggested that 6,000 mg of MSM improved pain and function without side effects in people with knee OA. Some preparations combine MSM with glucosamine to treat OA.
A human study concluded that MSM (3g twice a day) improved pain and physical function symptoms during the short intervention without significant adverse events.
A systematic review concluded that the data from the more rigorous MSM trials provide positive but not definitive evidence that MSM is superior to placebo in the treatment of mild to moderate osteoarthritis (OA) of the knee.
· Hyaluronic acid intra-articular (inside the joint) injections (viscosupplementation)
Hyaluronic acid has been used in attempts to treat osteoarthritis of the knee via injecting it into the joint. In 2007, the EMA (European Medicines Agency; a European Union (EU) agency for the evaluation of medical products) extended its approval of Hylan GF-20 as a treatment for ankle and shoulder osteoarthritis pain.
Injections of hyaluronic acid (such as Hyalgan, Synvisc, Artzal, and Nuflexxa) into the joint, a procedure called viscosupplementation, may provide pain relief for knee osteoarthritis. Relief usually lasts several months. Some studies report that these injections provide modest pain relief at best.
Viscosupplementation is injecting an artificial joint fluid called hyaluronic acid into the knee to cushion the joint. It may provide temporary relief of pain for up to 6 months.
Viscosupplementation is a procedure in which a doctor injects hyaluronic acid preparation into the knee joint. Hyaluronic acid is a naturally occurring synovial (joint) fluid substance. It acts as a lubricant to enable bones to move smoothly over each other and as a shock absorber for joint loads. Patients with osteoarthritis have a lower-than-normal concentration of hyaluronic acid in their joints. Viscosupplementation may be a therapeutic option for individuals with osteoarthritis of the knee. Viscosupplementation has been shown to relieve pain in many patients who cannot get relief from non-medicinal measures. The technique has been used in Europe and Asia for several years, but the U.S.A. Food and Drug Administration (FDA) did not approve it until 1997, and then only for treating osteoarthritis of the knee. Several preparations of hyaluronic acid are now commercially available. Viscosupplementation can be helpful for people whose arthritis has not responded to primary treatments. It is most effective if the arthritis is in its preliminary stages (mild to moderate). The long-term efficacy of viscosupplementation is not yet known, and research continues. It may take several weeks for the patient to notice an improvement after viscosupplementation. Not all patients will have relief from pain. If the injections are effective, they may be repeated after a period of time, usually 6 months. Over the course of the injections, the patient may notice that he/she has less pain in the knee. Hyaluronic acid does seem to have anti-inflammatory and pain-relieving properties. Effects may last for several months. Viscosupplementation may be effective in relieving the symptoms of arthritis but has never been shown to reverse the arthritic process or re-grow cartilage.
A Cochrane review assessed the effects of viscosupplementation in the treatment of osteoarthritis (OA) of the knee. The products were hyaluronan and hylan derivatives. Randomized controlled trials (RCTs) of viscosupplementation for the treatment of people with a diagnosis of OA of the knee were included. Single and double-blind studies, placebo-based, and comparative studies were eligible. Seventy-six (76) trials with a median quality score of 3 (range 1 to 5) were identified. Overall, the analyses performed are favorable for the hyaluronic acid (HA) class and mainly positive for some products concerning specific variables and time points, such as pain on weight-bearing at 5 to 13 weeks post (after) – injection. In general, sample-size restrictions preclude any definitive comment on the safety of the HA class of products; however, within the constraints of the trial designs employed, no significant safety issues were detected. In some analyses, viscosupplements were comparable in efficacy to active systemic intervention, with more local reactions but fewer systemic adverse events. In other studies, HA products had more prolonged effects than IA (intraarticular, i.e., inside the joint (injection)) corticosteroids. Overall, the analyses mentioned above support the use of hyaluronic acid (HA) products in treating knee osteoarthritis (OA).
A review evaluated whether intra-articular (injected) in the joint) hyaluronic acid is efficacious in treating knee osteoarthritis (OA). The review concluded that intra-articular hyaluronic acid has a small effect compared with an intra-articular placebo. The presence of publication bias suggests even this effect may be overestimated. Compared with lower-molecular-weight hyaluronic acid, the highest-molecular-weight hyaluronic acid may be more efficacious in treating knee OA (osteoarthritis). Still, the heterogeneity of these studies limits definitive conclusions.
Hyaluronic acid may have some in vitro anti-inflammatory activity and a possible disease-modifying effect for hyaluronic acid in animals. Hyaluronic acid, as weekly intra-articular (inside the joint) injections for 3 to 7 weeks, improves knee pain and joint motion in patients with osteoarthritis. Although this occurred to a higher degree than with placebo in most comparisons, the effects of hyaluronic acid were similar to those of a placebo in the larger trial. In the few available comparisons with other agents, hyaluronic acid appeared equivalent to methylprednisolone 40 mg (for 3 weeks) and to a single injection of triamcinolone 40 mg (both these drugs are synthetic corticosteroids). Hyaluronic acid was distinguished from other therapies by providing a sustained effect after treatment discontinuation. Together with its excellent tolerability profile, these properties justify further study of hyaluronic acid in patients with osteoarthritis. There is also some limited evidence of improvement in patients with rheumatoid arthritis.
Although the predominant mechanism of intra-articular (inside the joint (injection)) hyaluronan (hyaluronic acid) (HA) and hylans for the treatment of pain associated with knee osteoarthritis (OA) are unknown, in vivo, in vitro, and clinical studies demonstrate various physiological effects of exogenous HA. HA can reduce nerve impulses and nerve sensitivity associated with the pain of OA. In experimental OA, this glycosaminoglycan has protective effects on cartilage, which may be mediated by its molecular and cellular effects observed in vitro. Exogenous (that is administered to a subject) hyaluronic acid (HA) enhances chondrocyte (cartilage cell) hyaluronic acid and proteoglycan synthesis, reduces the production and activity of pro-inflammatory mediators and matrix metalloproteinases, and alters the behavior of immune cells. Many of the physiological effects of exogenous HA may be a function of its molecular weight.
A study assessed the efficacy and adverse events of intraarticular (inside the joint (injection)) hyaluronic acid in knee osteoarthritis patients. In the study, patients were referred to a large primary care center for the management of osteoarthritis of the knee. Of 897 referral patients, 537 met the criteria, and only 21 patients did not return for a second injection series. The study concluded that intraarticular (inside the joint) hyaluronic acid injections were highly effective in improving resting and walking pain in patients with osteoarthritis of the knee on a first and a second treatment series. The duration of symptom control was about 6 months, and the therapy was highly satisfactory to patients. It was associated with very few local adverse events and limited use of concomitant therapeutic modalities. This data supports the potential role of intraarticular hyaluronic acid as a useful long-term therapeutic option for patients with osteoarthritis of the knee.
A review compared the efficacy of intra-articular (inside the joint (injection)) hyaluronic acid with corticosteroids for knee osteoarthritis (OA). The review concluded that from baseline to week 4, intra-articular (inside the joint (injection)) corticosteroids appear to be relatively more effective for pain than intra-articular hyaluronic acid. However, by week 4, the 2 approaches had equal efficacy, but beyond week 8, hyaluronic acid had greater effectiveness. Understanding this trend is useful to clinicians when treating knee osteoarthritis (OA).
A review determined whether viscosupplementation with intra-articular hyaluronic acid (HA) injections improves pain and function in patients with osteoarthritis (OA) in their knees. Five case series and 13 RCTs (randomized controlled trials) were critically appraised. Data from three case series and three RCTs using high-molecular-weight HA (Synvisc) injections demonstrated significant improvement in pain, activity levels, and function. The beneficial effect started as early as 12 weeks. Studies using low-molecular-weight HA had conflicting results. The review concluded that viscosupplementation with high-molecular-weight hyaluronic acid (HA) is an effective treatment for patients with knee osteoarthritis (OA) who have ongoing pain or are unable to tolerate conservative treatment or joint replacement. Viscosupplementation appears to have a slower onset of action than intra-articular steroids, but the effect seems to last longer.
A meta-analysis suggests that intra-articular (inside the joint (injection)) hyaluronic acid (IAHA) is not significantly different from continuous oral (taken by mouth) non-steroidal anti-inflammatory drugs (NSAIDs) at 4 and 12 weeks. The study detected no safety concerns; however, the included trials had only a short follow-up duration. Given the favorable safety profile of IAHA over NSAIDs, this result suggests that IAHA might be a viable alternative to NSAIDs for knee OA, especially for older patients at higher risk for systemic adverse events.
· Hyaluronic acid – oral (taken by mouth)
A double-blind, randomized, placebo-controlled study of 40 subjects over a period of 3 months investigated the effects of an oral (taken by mouth) preparation containing hyaluronic acid on osteoarthritic knee joint pain and function as well as changes in inflammatory cytokines, bradykinin, and leptin. In 20 subjects, terminal heavy water ingestion was used for spectral analyses of serum and joint fluid samples. The results showed that there were statistically significant improvements in pain and function. In the oral hyaluronic acid preparation group, both serum and synovial fluid samples showed substantial decreases in most inflammatory cytokines, leptin, and bradykinin. Heavy water analyses revealed a significant reduction of hyaluronic acid turnover in the synovial fluid of the treatment group. In conclusion, a preparation containing hyaluronic acid and other glycosaminoglycans holds promise as a safe and effective agent for the treatment of patients with knee osteoarthritis who are overweight.
A study investigated the efficacy of oral (by mouth) hyaluronic acid (HA) administration for osteoarthritis (OA) in knee joints. Sixty osteoarthritic subjects (Kellgren-Lawrence grade 2 or 3) were randomly assigned to the HA or placebo group. The subjects in the HA group were given 200 mg of HA once a day every day for 12 months, while the subjects in the placebo group were given a placebo. The subjects in both groups were requested to conduct quadriceps strengthening exercises daily as part of the treatment. The Japanese Knee Osteoarthritis Measure (JKOM) score evaluated the subjects' symptoms. The symptoms of the subjects, as determined by the JKOM score, improved with time in both the HA and placebo groups. This improvement tended to be more obvious in the HA group, and this trend was more evident in subjects aged 70 years or under. For these relatively younger subjects, the JKOM score was significantly better than the one for the placebo group at the 2nd and 4th months after the initiation of administration. The study concluded that oral (by mouth) administration of hyaluronic acid (HA) may improve the symptoms of knee osteoarthritis (OA) in patients aged 70 years or younger when combined with the quadriceps strengthening exercise.
A randomized, double-blind controlled study examined the effect of dietary supplementation with a natural extract of chicken combs with a high content of hyaluronic acid (60%) (Hyal-Joint) (active test product, AP) on pain and quality of life in subjects with osteoarthritis of the knee. Twenty subjects aged equal to or more than 40 years with knee osteoarthritis (pain for at least 15 days in the previous month, symptoms present for equal or more than 6 months, Kellgren/Lawrence score equal or more than 2) participated in the trial. Ten subjects received AP (80 mg/day), and ten subjects received a placebo for 8 weeks. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and quality of life by the Short Form-36 (SF-36v2) were administered at baseline and after 4 and 8 weeks of treatment. In conclusion, this pilot clinical trial showed that daily supplementation with oral hyaluronic acid from a natural extract of chicken combs (Hyal-Joint) was useful in enhancing several markers of quality of life in adults with osteoarthritis of the knee. The results warrant further study in larger sample sizes.
· Omega – 3 fatty acids/ fish oil
Lab studies suggest that diets rich in omega-3 fatty acids (and low in inflammatory omega-6 fatty acids) may help people with osteoarthritis, although more research is needed.
· New Zealand green-lipped mussel (Perna canaliculus)
A potential source of omega-3 fatty acids. It has been reported to reduce joint stiffness and pain, increase grip strength, and improve walking pace in a small group of people with osteoarthritis.
A study showed that dietary n-3 (omega-3) polyunsaturated fatty acid (PUFA) reduced disease in osteoarthritis (OA) – prone animals.
· Pomegranate
In vitro studies showed that pomegranate extract blocked the production of an enzyme that destroys cartilage in the body
A study concluded with the suggestion that pomegranate extract (PE) or PE-derived compounds may be developed as MKK and p38-MAPK inhibitors for the treatment of OA and other degenerative/inflammatory diseases.
· Proanthocyanidins/ oligomeric proanthocyanidin complexes (OPCs)/ Grape seed proanthocyanidin extract (GSPE)
It is protective against joint damage in the MIA-treated rat model of osteoarthritis. Thus, GSPE could open up novel avenues for the treatment of osteoarthritis.
· Resveratrol
A study concluded that resveratrol seems to be an effective in vitro anti-inflammatory agent and has a chondroprotective (protective for the cartilage) capacity through suppression of (1) IL-1beta, (2) ROS (reactive oxygen species), and (3) tumor suppressor protein p53-production.
· SAMe (S-adenosylmethionine)
SAMe has anti-inflammatory and analgesic (alleviates the pain) effects and has been reported to ameliorate the pain and dysfunction of osteoarthritis (OA).
A number of well-designed clinical trials show that SAMe may reduce pain and inflammation in the joints. Researchers think it may also promote cartilage repair. In several short-term studies, SAMe supplements were as effective as nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, in adults with knee, hip, or spine osteoarthritis.
SAMe was as effective as these medications in lessening morning stiffness, decreasing pain, reducing swelling, improving range of motion, and increasing the walking pace.
Several studies also suggest that SAMe has fewer side effects than NSAIDs.
Another study compared SAMe to celecoxib (Celebrex (R)), a type of NSAID called a COX-2 inhibitor, and found that SAMe was as effective as celecoxib in relieving pain.
A study concluded that SAMe has a slower onset of action but is as effective as celecoxib in the management of symptoms of knee osteoarthritis.
A meta-analysis concluded that SAMe appears to be as effective as NSAIDs in reducing pain and improving functional limitation in patients with osteoarthritis (OA) without the adverse effects often associated with NSAID therapies.
SAMe has shown equivalent benefits to various doses of the NSAIDs indomethacin, ibuprofen, and naproxen.
Note: S-Adenosyl-L-methionine (SAMe) has been shown to cause Parkinson’s disease-like effects that include hypokinesia, tremor, rigidity, and abnormal posture. The results of a study showed that SAMe caused hypokinesia, tremor, stiffness, and abnormal posture in rats. Motor activity was significantly decreased within 2 min post (after)-injection.
· Tart cherries
A human study showed that the trend toward decreased inflammatory indices (CRP and NO) after cherry consumption proves that cherries' compounds may inhibit inflammatory pathways.
A study in rats showed that tart cherry anthocyanins may have a beneficial role in the treatment of inflammatory pain – the antihyperalgesic effects may be related to the anti-inflammatory and antioxidant properties of anthocyanins (hyperalgesia is an increased sensitivity to pain that may be caused by damage to nociceptors or peripheral nerves).
· Hydrolyzed collagen
A human study concluded that BioCell Collagen (BCC), a low molecular weight dietary supplement consisting of hydrolyzed chicken sternal cartilage extract, was well tolerated, and found to be effective in managing osteoarthritis (OA)-associated symptoms over the study period, thereby improving patient’s activities of daily living; thus, BCC can be considered a potential complement to current OA therapies.
Another human study concluded that the novel glycosylated undenatured type II collagen material (UC-II) may serve as a novel therapeutic tool in joint inflammatory conditions and symptoms of osteoarthritis (OA) and rheumatoid arthritis (RA)].
· Celadrin™ (cetylated fatty acids) [topical use as a joint cream or taken orally as capsules or soft gels]
A human study showed that one week of treatment with a topical cream consisting of cetylated fatty acids (Celadrin) and menthol was similarly effective for reducing pain and improving functional performance in individuals with arthritis of the knee, elbow, and wrist; these data support the use of a topical cream consisting of cetylated fatty acids (with or without menthol) for enhancing the potential for exercise training in this population.
Another human study concluded that compared to a placebo, CFA (cetylated fatty acids; Celadrin) provides an improvement in knee range of motion and overall function in patients with osteoarthritis (OA) of the knee; thus, CFA may be an alternative to the use of non-steroidal anti-inflammatory drugs (NSAIDs) for the treatment of OA.
A human study concluded that 30 days of treatment with a topical cream consisting of cetylated fatty acids improves static postural stability in patients with knee osteoarthritis (OA), presumably due to pain relief during quiet standing. Such over-the-counter treatment may help improve the exercise trainability of people with OA.
Another human study in patients diagnosed with osteoarthritis (OA) of one or both knees concluded that the use of a cetylated fatty acids (CFAs) topical cream is an effective treatment for improving knee range of motion (ROM), ability to ascend/descend stairs, ability to rise from sitting, walk and sit down, and unilateral balance.
· Arnica (e.g., Arnica Montana)
A human study in patients with radiologically confirmed and symptomatically active osteoarthritis of interphalangeal hand joints concluded that arnica preparation is not inferior to ibuprofen [an NSAID (non-steroidal anti-inflammatory drug) medication] when treating osteoarthritis of hands.
A human study concluded that the topical application of Arnica montana gel for 6 weeks was a safe, well-tolerated, and effective treatment of mild to moderate knee osteoarthritis (OA).
Note: Arnica is generally safe when used on the skin. However, using it for a long time may irritate the skin, causing eczema, peeling, blisters, or other skin conditions. Arnica should not be used on broken skin, such as leg ulcers. People should not take arnica by mouth without direct medical supervision, except in dilute form as a homeopathic remedy, because side effects may be severe.
· Cat’s claw
It has been used traditionally to treat osteoarthritis (OA); one study found that it may help relieve pain from knee OA without any significant side effects.
A human study concluded that Cat's claw is an effective treatment for osteoarthritis; the species Uncaria guianensis and Uncaria tomentosa are equiactive; they are effective antioxidants, but their anti-inflammatory properties may result from their ability to inhibit TNF-alpha and to a lesser extent PGE2 production.
· Piperine – black pepper
A study assessed the effects of piperine, the active phenolic component in black pepper extract, on human OA chondrocytes (cartilage cells); the study demonstrated the anti-inflammatory activity of piperine in human osteoarthritis (OA) chondrocytes (cartilage cells); piperine can effectively abrogate the IL-1beta -induced over-expression of inflammatory mediators; suggesting that piperine may be a potential agent in the treatment of OA.
· Epimedium (Horny goat weed)
The Chinese traditional herb Epimedium grandiflorum had long been found to attenuate osteoarthritis, but the detailed mechanism was not precise. A study investigated the mechanisms of E. grandiflorum in the treatment of osteoarthritis rabbit osteoarthritis model combined with D-galactose. After different treatments for 10 weeks, cartilage sections were analyzed. The results showed that Epimedium grandiflorum and its extract icariin could attenuate osteoarthritis (OA) conditions, reduce the expression of uPA and uPAR, and increase PAI in an experimental rabbit model. This effect may be conducted by suppressing NF-kappaB activity by increasing IkappaBalpha level].
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