Natural gains against the pain of arthritis
Some therapies may offer more than pain relief
The vast majority of Americans using complementary therapies are those seeking relief from some kind of pain: arthritis, chronic back pain, and musculoskeletal pain. Arthritis pain alone has driven more Americans to seek complementary and alternative medicine (CAM) therapies than any other single affliction. And although most patients using CAM therapies for arthritis employ them as a supplement to rather than a replacement for mainstream medical care, they tell researchers they do so because their medications do not provide complete relief.
"Whatever the reason, the use of CAM therapies corresponds to the severity of the pain, and some patients do find pain relief with the CAM therapies they use," says Sharon Kolasinski, MD, FACP, FACR, assistant professor of medicine, chief of clinical service of the Division of Rheumatology and director of the Rheumatology Fellowship Program at the University of Pennsylvania in Philadelphia.1 "In treating arthritis, we don’t have a cure for anything, so anything that provides relief is certainly worth a try," she adds.
Glucosamine and chondroitin
The use of glucosamine sulfate with or without chondroitin sulfate is "by far and away" the most popular supplement for the treatment of osteoarthritis. Glucosamine is extracted from the shells of crustaceans, and chondroitin is prepared from cow trachea or shark cartilage. Glucosamine has been reported to inhibit cartilage breakdown and stimulate regeneration of cartilage after damage. Chondroitin has been reported to block the enzymes that degrade cartilage.
Both supplements have been used for many years in Germany and other parts of Europe, and although their effects on joint damage are being debated, most medical experts agree that glucosamine works as an anti-inflammatory, reduces pain, and is safe. "Glucosamine has about the same potential for pain relief as NSAIDs [nonsteroidal anti-inflammatory drugs]," says Kolasinski. "Many of my patients take it, and a good number of them get relief."
The best evidence available to date is a large three-year Belgian study that suggests that glucosamine slows the progression of osteoarthritis.2 A similar placebo-controlled trial is underway in the United States under the auspices of the National Institutes of Health (NIH) and will include chondroitin, glucosamine-chondroitin, and NSAID arms.
The evidence in favor of chondroitin is less convincing, and there have been no clinical trials published on the popular combination of the two supplements. It remains unclear whether patients get any additional benefits by taking glucosamine and chondroitin together.
The operative daily dose for the subjects of the Belgian study was 1,500 mg of glucosamine. It often is divided into two or three doses, and it may take four to eight weeks for effects to become noticeable. Chondroitin usually is used in similar dosages. If neither has an effect within 12 weeks, patients usually are advised to discontinue use.
Because glucosamine may affect glucose metabolism, it is not recommended for patients with diabetes until further trials provide better information on its effects on blood glucose levels.
Massage
"Massage improves circulation throughout the entire body," says John Balletto, LMT, NCTMB, president of the American Massage Therapy Association (AMTA) Foundation in Providence, RI. "So by bringing fresh nutrients to the joint and muscle tissues, it helps them work more effectively."
A recent survey shows that more than half of osteoarthritis sufferers use massage therapy.3 A study from the University of Miami on children with rheumatoid arthritis showed that subjects with mild-to-moderate forms of the disease who were massaged for 15 minutes daily by their parents for 20 days, experienced immediate lowering of anxiety and stress as measured by cortisol levels, decreased pain, and increased joint mobility.4
"Massage is an analgesic, it calms the central nervous system and breaks the pain pattern," says Balletto. The most effective massage techniques, he says, are stroking, called effleurage in traditional massage, and passive joint movement to increase mobility. "You don’t want anything too extreme, but any movements that help the joint move more freely," he says.
Patients can be taught simple self-massage techniques that can be very helpful, especially for arthritic conditions of the hands, wrists, and elbows. Balletto recommends referring patients to trained and certified massage therapists through the AMTA locator service on the Internet at www.amtamassage.org. All members of the organization hold national certifications and state licenses if they practice in one of the 31 states that require licensure.
Locating the pressure points
Acupuncture, an ancient Chinese treatment, and acupressure, its noninvasive cousin, have become widely accepted in the United States for a variety of medical conditions. Acupuncture treatments, as prescribed by traditional Chinese medicine, typically involve the insertion of hair-fine needles into the skin along defined tracts called meridians, where they help stimulate the flow of "qi" or "chi," vital life energy.
Acupressure and shiatsu massage, a Japanese form of acupressure, use no needles, but stimulate the same meridians by applying pressure to certain points on the body. Qualified practitioners can teach patients acupressure techniques. "Acupuncture and acupressure definitely have a place in pain management in arthritis," says Kolasinski, who frequently sends her arthritis patients for acupuncture treatments.
A Japanese animal study showed that electrically controlled acupuncture needles appear to delay the onset and reduce the severity of arthritis while reducing the collagen antibody levels. Researchers speculate that acupuncture may inhibit the production of endogenous interleukin-1 beta and prostaglandin by suppressing interleukin and COX-2 gene activations.5
After a 1998 consensus panel’s review of the available public data, the NIH concluded that acupuncture is a promising treatment for postoperative pain and for nausea and vomiting associated with chemotherapy. The agency also has approved the use of acupuncture as primary or adjunctive therapy for osteoarthritis, tennis elbow, fibromyalgia, myofascial pain, low back pain, and carpal tunnel syndrome.
Food sensitivities, vitamins, and herbs
Researchers have long contended that food sensitivities trigger the inflammation of rheumatoid arthritis and perhaps even exacerbate the symptoms of osteoarthritis. "Not all patients show food sensitivities, but for many, identifying food sensitivities has made an enormous difference.
Some of these patients had suffered with arthritis for years, never realizing that simple diet changes could help," says Neal Barnard, MD, president of the Washington, DC-based Physicians Committee for Responsible Medicine and author of Foods That Fight Pain, (New York City: Three Rivers Press; 1999). Barnard theorizes that some autoimmune responses are triggered by food sensitivities, particularly to certain types of proteins. (See food tips, below.)
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The key, says Barnard, is to put patients on a supervised elimination test for several days, eliminating suspect foods, and then re-introducing them one at a time to identify specific triggers. "The most common triggers, by far, are proteins in dairy products and eggs, followed by corn and peanuts," says Barnard, who says in his experience, food sensitivities appear in 20% to 60% of subjects.
The theory was tested by a Norwegian study published in Lancet in 1991 in which common arthritis food triggers were eliminated with what Barnard calls "dramatic" results: "Joint stiffness melted away, swelling and tenderness decreased, and grip strength improved. The average pain score dropped from greater than 5 on a 10-point scale to less than 3. Most importantly, when patients were checked a year later, the benefits were still there."6 A vegetarian diet appears to benefit about 50% of patients, including those without specifically identified food triggers, says Barnard.
The jury is still out, but the Framingham Heart Study suggests that vitamins D supplementation may be helpful in alleviating symptoms of osteoarthritis and preventing deterioration.7 And positive results also have been reported for supplementation with vitamins C, E, B1, and B6, niacin, and folate, says Kolasinski. Patients should be advised not to exceed 400 IU of vitamin D daily because higher dosages have been shown to be toxic.
Herbal anti-inflammatories such as willow bark, devil’s claw, feverfew, and Chinese thunder god vine also may have some pain-relieving effects. Other commonly used, herbal anti-inflammatories include boswellia, turmeric, ginger, and nettles. There also have been reports that supplementation with fish oil may be beneficial.
References
1. Kolasinski SL. Complementary and alternative therapies for rheumatic disease. Hosp Pract 2001; 36:31-36, 39.
2. Reginster JY, et al. Long-term effects of glucosamine sulphate on osteoarthritis progression: A randomised, placebo-controlled clinical trial. Lancet 2001; 357:251-256.
3. Ramsey SD, et al. Use of alternative therapies by older adults with osteoarthritis. Arthritis Rheum 2001; 45:222-227.
4. Field T, et al. Juvenile rheumatoid arthritis: Benefits from massage therapy. J Pediatr Psychol 1997; 22:607-617.
5. Fang JQ, et al. Inhibitory effect of electroacupuncture on murine collagen arthritis and its possible mechanisms. In Vivo 1999; 13:311-318.
6. Kjeldsen-Kragh J, et al. Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis. Lancet 1991; 338:899-902.
7. McAlindon TE, et al. Relation of dietary intake and serum levels of vitamin D to progression of osteoarthritis of the knee among participants in the Framingham Study. Ann Intern Med 1996; 125:353-359.
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