Positive Health Online

Arthritis is one of the most debilitating diseases of modern times. It is thought that 90% of people in the UK will suffer from some form of arthritis by the time they reach 60 years of age. Quality of life for sufferers and their families is severely affected.

There are two forms of arthritis:

Rheumatoid Arthritis (RA) is a chronic inflammatory condition that affects the lubricating mechanism and cushioning of joints. It is an autoimmune disease in which the immune system attacks the joints and other parts of the body. Bone surfaces are destroyed and the bones fuse together creating stiffness, swelling, fatigue and crippling pain.

Osteoarthritis, the most common form of arthritis, results primarily from a progressive degeneration of cartilage glycosaminoglycans (GAG). The smooth surface of the cartilage becomes rough and this results in friction. The joint becomes deformed, painful and stiff, and the muscles holding the joint together become weak (see Figures 1 above and 2 below). Osteoarthritis affects the weight-bearing joints like knees, hips and ankles, and tends to be more common in older people.

Figure 1

Figure 2

The cumulative effects of decades of use and mis-use leads to degenerative changes in joints. This damage is further compounded by a decreased ability by the body to repair joint structures, much of which can be attributed to poor nutritional status.

Orthodox medications

There is a great deal of research indicating that the drug therapy used in osteoarthritis may produce short term benefit, but actually accelerates the progression of joint destruction. Standard drug therapy suppresses pain and inflammation, but actually promotes progression of the disease process by inhibiting GAG synthesis and cartilage repair.[1,2]

So, whilst these drugs are fairly effective in suppressing the symptoms, they possibly worsen the condition by inhibiting cartilage formation and accelerating cartilage destruction.

Aspirin is commonly used as a pain reliever and anti-inflammatory. However, high doses are required to achieve efficacy and these can be associated with side effects such as tinnitus and gastric irritation. Other non-steroidal, anti-inflammatory drugs (NSAIDs) such as ibuprofen and indomethacin are also associated with side effects including gastrointestinal upset, headaches and dizziness. Long term usage is therefore not recommended.

Natural Approaches

Nutritional intervention may well give relief to many sufferers of these debilitating conditions and this review will discuss several of the well researched natural agents that may be incorporated into a regime to help relieve the pain and inflammation associated with degenerative joint disease, concentrating mainly on osteoarthritis.
Boswellia (Boswellia serrata) has traditionally been used for a myriad of disorders and today its major use is as an anti-inflammatory agent for musculoskeletal problems.

Research has compared Boswellia with non-steroidal, anti-inflammatory agents and it has been shown to be as effective with fewer side effects. Non-steroidals such as ibuprofen can cause gastrointestinal side effects, but Boswellia has no such activity.

The mechanism of action of Boswellia is still not fully understood, but it is thought to be due to the Boswellic acid and its derivatives exerting anti-inflammatory effects by reducing the inflammatory and immune response, which leads to faster healing.[3]

Due to its inhibitory effects on the immune system, Boswellia is not recommended for pregnant women or those with compromised immune functions. Boswellic acid has shown to be a potent 5-lipoxygenase inhibitor. (5-lipoxygenase is an enzyme, which stimulates eicosanoids to be produced from fatty acids thus causing an increase in pain and inflammation.)[3,4]

Curcumin (Curcuma longa) is the yellow pigment and active component found in the spice turmeric, obtained from the powdered rhizomes of the plant Curcuma longa. It is commonly used as a colouring agent in foods. Curcumin appears to have a variety of actions that make it a potent anti-inflammatory agent, including its ability to scavenge nitric oxide, act as an antioxidant, inhibit synthesis of interleukin-1 and tumour necrosis factor, and inhibit lipoxygenase and cyclo-oxygenase.[5,6,7]

Curcumin has also been shown to induce the production of glutathione, suggesting it may be beneficial in conditions of impaired detoxification.[8]

Curcumin has been used clinically as an anti-inflammatory for conditions such as post-operative inflammation, rheumatoid arthritis and osteoarthritis.[9,10,11]

White Willow (Salix alba) contains bitter phenolic and flavonoid glycosides. The most active is salicin, which is converted in the liver to acetyl-salicylic acid, an effective anti-inflammatory agent, but which does not have the gastrointestinal toxicity associated with aspirin (salicylic acid).

The salicylates inhibit the activity of the cyclo-oxygenase enzyme and thus inhibit the production of prostaglandins, which can lead to a reduction in pain and inflammation.[12]

Ginger (Zingiber officinale) is another well-known culinary herb which has been studied and contains gingerol, an active phenylketone which has a structure similar to aspirin, which may explain the similar effect these two compounds have on prostaglandins.[13,14,15]

A small clinical study in Denmark involving seven patients, who took an average of 5g of fresh ginger daily for three months, reported less pain, better mobility and a reduction in swelling and stiffness.[16]

MSM (Methyl Sulphonyl Methane) is an organic salt found in plants and animals and manufactured in the body from sulphur-containing amino acids. It is a primary sulphur donor which has antioxidant properties. Studies have demonstrated the efficiency in reducing the signs of arthritis in animals. It may also inhibit autoimmune reactions.[17,18,19]

Glucosamine sulphate is one of the most well-known and well-researched formulas for improving joint health. Glucosamine sulphate (GS) provides the joints with the building blocks they require to repair the damage caused by osteoarthritis. GS is a simple molecule composed of glucose, an amine (nitrogen and two molecules of hydrogen) and sulphur. GS stimulates the formation of chondrocytes (cartilage cells), which helps to build up the cartilage matrix by converting glucosamine into proteoglycans. As well as this, GS promotes the incorporation of sulphur into cartilage. Therefore GS not only stimulates the manufacture of substances necessary for proper joint function, it is also responsible for stimulating joint repair.[20]

It appears that as some people age they lose the ability to manufacture significant amounts of glucosamine, resulting in cartilage that can no longer carry out its role efficiently. This could be a major factor leading to osteoporosis.

Because GS is a relatively small molecule it is easily absorbed and travels primarily to joint tissue where it is incorporated into cartilage.

The sulphur component of GS appears to play a critical role in the beneficial effects noted from this compound. Sulphur is an essential nutrient for joint tissue where it functions in the stabilization of the connective tissue matrix of cartilage, tendons and ligaments. As far back as the 1930s, researchers demonstrated that individuals with arthritis are commonly deficient in this essential nutrient.[21] Restoring sulphur levels brought about significant benefit to these patients.[22] Other essential nutrients required for joint function include vitamin C for collagen formation and copper as a co-enzyme for lysyl-oxidase, essential for the conversion of collagen and elasticin.

Clinical trials

Numerous double-blind studies have shown GS to produce much better results compared to NSAIDS and placebos in relieving the pain and inflammation associated with osteoarthritis.[23,24]

In one study comparing GS to ibuprofen, pain scores decreased faster in the first two weeks in the ibuprofen group (see Figure 3 below);[24 ] however, by the 4th week the group receiving GS was doing significantly better than the ibuprofen group.[24]

Figure 3: Comparison of pain scores between glucosamine sulphate and ibuprofen

In another large open trial carried out in Portugal,[25] patients receiving 500mg of oral GS three times a day over a period of approximately 50 days, showed a significant improvement in mobility and a reduction in pain. Overall, 95% of patients achieved benefit from GS. Both doctors and patients rated the GS as being significantly better than NSAIDs.

NSAIDs tend to offer purely symptom relief, and as described earlier, may even exacerbate the disease. GS appears to address the cause of osteoarthritis by getting to the root of the problem, therefore GS not only relieves pain but also can help with the repair of damaged joints. This is truly outstanding considering its safety and lack of side effects.

The latest findings of a large, three year European study of the effects of GS were recently presented at The American College of Rheumatology.[26] Before and after X-rays of 212 osteoarthritis patients showed that 22% of those taking a daily 1500mg supplement of GS had deterioration in their knee joints compared to 38% of patients taking a placebo. Over the three years, pain, stiffness and physical function improved in the glucosamine group but worsened in the placebo group.

Which form is best? Glucosamine sulphate is available stabilized with one of two mineral salts: sodium chloride (NaCl) or potassium chloride (KCl). Although they both appear to be effective, the use of KCl is preferable as the average Western diet already provides far too much sodium chloride in the form of salt.

How much is usually taken? Most of the research into glucosamine sulphate uses 500mg three times daily, and there have been no reports of toxicity or side effects. As GS is not a drug, it may take a little longer to produce results and the benefits become more obvious the longer it is taken.

Summary

It can be seen that natural substances are important adjunctive agents in the treatment of inflammatory musculoskeletal conditions. By employing a natural approach, pain and inflammation may well be decreased, joint movement and flexibility improved and unpleasant side effects associated with drugs avoided.

References

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2. Shied MJ. Anti-inflammatory drugs and their effects on cartilage synthesis and renal function: Eur J Rheumatol Inflam. 13: 7-16. 1993.
3. Ammon HP, Safayhi H, Mack T, Sabieraj J. Mechanism of anti-inflammatory actions of curcumin and boswellic acids. J Ethnopharmacol. 38(2-3): 113-119. Mar 1993.
4. Boswellia serrata: A unique Ayurvedic Anti-Rheumatic. Vitamin Research Products Inc. May/June 1996.
5. Sreejayan, Rao MN. Nitric oxide scavenging by curcuminoids. J Pharm Pharmacol. 11: 1551-1556. 1995.
6. Chan MM. Inhibition of tumor necrosis factor by curcumin, a Phytochemica. Biochem Pharmacol. 11: 1551-1556. 1995.
7. Huang M-T, Lyszt, Ferraro T, Abidi TF, Laskin JD, Conney AH. Inhibitory effects of curcumin on in vitro lipoxygenase and cyclooxygenase activities in mouse epidermis. Cancer Res. 51: 813-819. 1991.
8. Susan M, Rao MNA. Induction of glutathione S transferase activity by curcumin in mice. Drug Res. 42(7): 962-964. 1992.
9. Satoskar RR, Shah SJ, Shenoy SG. Evaluation of anti-inflammatory property of curcumin (diferuloyl methane) in patients with post operative inflammation. Int J Clin Pharmacol Therapy Toxicol. 24: 651-654. 1996.
10. Deodhar SD, Sethir, Srimal RC. Preliminary study on anti-rheumatic activity of curcumin. Ind J Med Res. 71(12): 632-634. 1980.
11. Kulkarni RR, Patki PS, Jog VP, et al. Treatment of Osteoarthritis with a herbomineral formulation: a double blind, placebo controlled, crossover study. J Ethnopharmacol. 33: 91-95. 1991.
12. Flynn R, Roest M. Your Guide to Standardized Herbal Products. World Press. 1995.
13. Srivastava KC, Mustafa T. Ginger (Zingiber Officinale) in rheumatism and musculoskeletal disorders. Med Hypotheses. 39(4): 342-348. Dec 1992.
14. Kiuchi F, Iwakami S, Shibuya M, Hanaoka F, Sankawa U. Inhibition of prostaglandin and leukotriene biosynthesis by gingerols and diarylheptanoids. Chem Pharm Bull (Tokyo). 40(2): 387-391. Feb 1992.
15. Srivastava KC, Mustafa T. Ginger (Zingiber Officinale) and rheumatic disorders. Med Hypotheses. 29(1): 25-28. May 1989.
16. Srivastava KC, Mustafa T. Ginger and rheumatic disorders. Med Hypotheses. 29: 25-28. 1989.
17. Beilke MA, Collins-Lech C, Sohnle PG. Effects of dimethyl sulfoxide on the oxidative function of human neutrophils. J Lab Clin Med. 110(1): 91-96. Jul 1987.
18. Murav'ev Iu V, Venikova MS, Pleskovskaia GN, Riazantseva TA, Sigidin IaA. Effect of dimethyl sulfoxide and dimethyl sulfone on a destructive process in the joints of mice with spontaneous arthritis. Patol Fiziol Eksp Ter. 2: 37-39. Article in Russian. Mar 1991.
19. Morton JI, Siegel BV. [Effects of oral dimethyl sulfoxide and dimethyl sulfone on murine autoimmune lymphoproliferative disease] [Russian]. Proc Soc Exp Biol Med. 183(2): 227-230. Nov 1986.
20. Glucosamine sulphate: effective osteoarthritis treatment. Am J Nat Med. 1(1): Sept 1994.
21. Sullivan MX and Hess WC: Cysteine content of finger nails in arthritis. J Bone Surg. 16: 185-8. 1935.
22. Senturia BD: Results of treatment of chronic arthritis and rheumatoid conditions with colloidal sulphur. J Bone Joint Surg 16: 119-25. 1934.
23. Puljalte JM, et al: Double blind clinical evaluation of oral glucosamine sulphate in the basic treatment of osteoarthritis. Curr Med Res Opin. 7: 110-4. 1980.
24. Vaz AL: Double blind clinical evaluation of the relative efficacy of ibuprofen and glucosamine sulphate in the management of osteoarthritis of the knee of out-patients. Curr Med Res Opin. 8: 145-9. 1982.
25. Tapandinhas MJ, et al. Oral glucosamine sulphate in the management of arthrosis: report on a multicentre open investigation in Portugal. Pharmatherapeutica. 3: 157-68.1982.
26. Dr Jean-Yves Reginster, University of Liege, Belgium. American College of Rheumatology. November 1999.