Osteoarthritis

Description

Natural Remedies

Glucosamine and chondroitin sulfate are natural substances that are part of the building blocks found in and around cartilage. Extracts from animal products have been used in Europe for more than a decade to reduce pain and improve mobility in patients with osteoarthritis. Both substances may possibly play a role in cartilage repair and maintenance.

Studies to date report the following for each substance:

• Glucosamine Sulfate. A number of major studies have now reported that glucosamine sulfate slowed or even prevented progression of joint changes that cause osteoarthritis.Some have found it to be equal or superior to NSAIDs in reducing pain. (One 2001 study theorized that sulfate may be important in the effectiveness of glucosamine and nonsulfate preparations may not have any benefits.)
• Chondroitin Sulfate. A review of seven European trials involving chondroitin sulfate indicated that pain scores dropped by about 60% with chondroitin versus only about 20% from placebo. A well-controlled 2001 study observed a beneficial trend after three months of treatment.

In general, it takes about eight weeks for these agents to be fully effective. They may be taken together, and, in fact, some studies report that they are more effective when taken together than when taken alone.Researchers are also investigating topical creams containing these substances. In one study, using a cream on the knee reduced pain significantly within four weeks.

Side Effects. At this time, few adverse side effects have been reported, and the safety records of both agents appear to be excellent. Long-term effects are still unknown, but studies of up to three years have reported no significant side effects. Of some concern are studies suggesting that glucosamine affects insulin and glucose (blood sugar) metabolism, which would be of great concern among diabetic and obese individuals. In an encouraging 2003 study, however, tests reported no changes in glucose metabolism people with diabetes who took glucosamine and chondroitin sulfate every day for three months.

A major US trial is under way to determine both risks and benefits. At this time, there are no standard dosages that can be recommended for people with osteoarthritis. Some studies reporting benefits used daily doses of 1500 to 2000 mg of glucosamine and 1200 mg or chondroitin sulfate. Potential users need to be aware that glucosamine and chondroitin products are not regulated by the FDA and the effectiveness and safety of particular brands cannot be guaranteed. An analysis of commonly available brands, however, suggests that major drugstore brands (e.g., CVS, Walgreens, Wal-Mart) of combination products are manufactured with appropriate ingredients. No one should take either or both agents without seeking medical advice.

Note: Some supplement products containing glucosamine and chondroitin sulfate include others ingredients, such as manganese. Excessive amounts of this mineral can cause liver damage and daily levels should not exceed 11 mg a day.

Injections of Hyaluronic Acid (Viscosupplementation)

Injections of hyaluronic acid (Hyalgan, Synvisc, Artzal) into the joint--a procedure called viscosupplementation--is now recommended as one of the treatments for osteoarthritis. Hyaluronic acid is a naturally occurring substance in joints that acts as a lubricant for slow movements and a shock absorber for fast motions. In high amounts, it also may have anti-inflammatory effects.

In general the procedure is as follows:

• The agent is administered by injection into the joint.
• Patients receive a series of three (Synvisc) to five (Hyalgan) injections given once a week.
• Because these products are viscous (sticky), administration requires a large needle, so a local anesthetic is applied.
• Patients are told to avoid weight-bearing activities for about 48 hours after each injection.

Hyaluronic injections appear to be about as effective as NSAIDs and corticosteroid injections for relieving pain, at least in men, and they have no adverse effects in the stomach or intestines. One study reported that between 39% and 56% of patients were at least nearly free of weight-bearing pain up to 24 weeks after the final injection. And in another study, response was judged better or much better for 87% of knees after a second course, which was administered about eight months later. Nevertheless, a number of studies on viscosupplementation have shown little or no benefits, particularly in women, and more work is needed to determine if they are useful. Injections are also expensive. Accurate placement of the needle directly into the knee joint space is important and may be difficult, even for experienced physicians, if there is no fluid build-up in the joint. Best success rates are with a specific approach into the kneecap called the lateral midpatellar.

Side Effects. Serious adverse reactions are rare, and the most common side effects, pain at the injection site and knee pain and swelling, are usually mild and temporary. More research is needed to confirm their benefits and long-term risks.

Other Investigative Alternative Substances

Oral Enzymes. Oral agents containing various natural enzymes, including bromelain, trypsin, papain, and rutin, have been used overseas to treat arthritic pain. Such enzymes have been marketed alone and in combinations (Wobenzym, Phlogenzym). They are not pain killers and any benefits derived from them may take several weeks. Animal studies and small human trials supported by the manufacturer have reported benefits, including reduction in inflammation and cartilage damage. There have been very few well-conducted human trials, however. Some are now under way.

Ginger (Zingiberaceae). A 2001 study of patients with knee arthritis found that swallowing an extract of the spice ginger reduced pain while standing and after walking, and patients were able to reduce their pain medications after six weeks. Side effects included mild digestive upset. Further testing is needed to assess long-term safety and benefits.

S-adenosylmethionine (SAMe). S-adenosylmethionine (SAMe, pronounced "Sammy") is a synthetic form of a natural byproduct of the amino acid methionine. It has been marketed as a remedy for both depression and arthritis. Existing research suggests that it may be about as effective as NSAIDs for short-term treatment of osteoarthritis, with few of the side effects of those drugs. Some studies suggest that it may even rebuild damaged cartilage. However, it is very expensive, and most studies have been poor designed. Better ones are needed before its true effectiveness and long-term safety can be determined. According to an analysis of current brands, reliable SAMe products include GNC, Natrol, Nature Made, The Vitamin Shoppe, Twin Laboratories, Source Naturals, NutraLife Health Products, and Puritan's Pride.

Acupuncture

Acupuncture is being used in an increasing number of medical clinics to reduce osteoarthritis pain, with some success. The technique is painless and involves the insertion of small fine needles at select points in the body. A review of seven studies of patients with osteoarthritis of the knee found that it provided at least short-term pain relief. Large scale trials are still lacking, and it is still possible that any benefits are due to a strong placebo effect. Nevertheless, it may be a safe and beneficial addition to standard therapy for certain patients, such as pregnant women, who cannot take most pain medications.

Acupuncture, hypnosis and biofeedback are all alternative ways to control pain. Acupuncture involves the insertion of tiny sterile needles, slightly thicker than a human hair, at specific points on the body.

Transcutaneous Electric Nerve Stimulation

Transcutaneous electric nerve stimulation (TENS) uses low-level electrical pulses to suppress pain. Patients are barely aware of the sensation. According to a 2003 study, the optimal treatment length is 40 minutes. A variant (sometimes called percutaneous electrical nerve stimulation, or PENS) applies these pulses through a small needle to acupuncture points. A 2001 analysis of seven trials reported that both methods were better than placebo (sham treatments) in treating osteoarthritis of the knee, although additional well-designed studies are needed.

Low-Level Laser Therapy

Some investigators are working with low-level laser therapy (LLLT), which generates extremely pure light in a single wavelength. It does not produce heat and is painless. Some researchers are combining LLLT with transcutaneous electric nerve stimulation (TENS). Studies report widely varying results, with some showing significant reductions in pain and others reporting no effect. The differences may be due to different approaches, and standardized methods are needed to determine any benefits.

Hydrotherapy

Hydrotherapy, also called spa therapy or balneotherapy, is an ancient therapy that uses bathing in mineral baths for soothing pain. Although many studies report positive results, including improved quality of life, very few have been rigorously conducted.A major analysis reports that evidence is very weak on any real effect on pain or quality of life, but some experts say that one should not ignore the benefits reported by patients from such pleasant therapy.