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Osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis. It is a joint disease caused by the breakdown of cartilage

-- the firm, rubbery tissue that cushions bones at joints.

Healthy cartilage allows bones to glide over one another and cartilage absorbs energy from the shock of physical movement. In OA cartilage breaks down and wears away. As a result, the bones rub together causing pain, swelling, and stiffness.

OA may also limit the range of motion in affected joints. Most often, OA develops in the hands, knees, hips, and

spine.

The disease affects men and women nearly equally. More than 20 million people in the United States have OA. Symptoms tend to appear when individuals are in their fifties and sixties.

Signs and Symptoms

Signs and symptoms of OA may include the following:

Joint pain (often a deep, aching pain) that is worsened by movement and improved with rest (in severe cases, a person may experience constant pain)
Stiffness in the morning or after being inactive for more than 15 minutes
Joint swelling
Joints that are warm to the touch
Crunching or crackling noise when the joint moves (crepitation)
Limited range of motion
Muscle weakness
Abnormal growth of bony knobs near joints which cause deformities (such as Heberden's nodes, in which bumps appear on the outermost finger joints)

Causes

Most of the time, the cause of OA is unknown. It is primarily a disease due to aging. However, metabolic, genetic,

chemical, and mechanical factors can play a role in its development.

Risk Factors

Risk factors for OA include:

Increasing age
Genetic predisposition
Obesity
Injury to the joint
History of inflammatory joint disease
Metabolic or hormonal disorders (such as hemochromatosis and acromegaly)
Bone and joint disorders present at birth
Repetitive stressful joint use (such as with certain occupations like baseball, ballet dancing and construction work)
Deposits of crystals in joints

Diagnosis

There is no single test to diagnose OA, so most doctors use a combination of methods to diagnose the disease and rule out the possibility other causes. A physical exam can show limited range of motion, grating of a joint with motion, joint swelling, and tenderness. An x-ray of affected joints will show loss of the joint space and, in advanced cases, wearing down of the ends of the bone and bone spurs.

Preventive Care

The following measures may reduce the risk of developing OA:

Protecting an injured joint from further damage
Exercising
Losing weight
Avoiding excessive repetitive motions
Providing proper nutritional support

Treatment Approach

The goals of treatment are to relieve pain, maintain or improve joint mobility, increase the strength of the joints, and minimize the disabling affects of the disease. The specific treatment depends upon the affected joints. A combination of conventional treatment and complementary and alternative medicine (CAM) may be most effective. Lifestyle approaches, including exercise, and many alternative medical therapies are becoming more popular and are considered safe and effective for the treatment OA.

Several natural remedies are at least as effective as conventional medication for symptom relief, and may help keep the disease from getting worse. Americans spend more on natural remedies for OA than for any other medical condition. In 1997, researchers conducted various surveys and found that anywhere from 26 -100% of patients with painful conditions of the muscles, tendons, joints, and bones had tried some form of complementary and alternative medicine.

Some of the most promising complementary approaches for treating OA include:

Reducing physical stress on the joint (lose weight and improve posture)
Lifestyle changes (particularly exercise)
Supplements including S-adenosylmethionine (SAMe), glucosamine and/or chondroitin, and antioxidants
Herbs with anti-inflammatory properties, including devil's claw, willow bark, and capsaicin (cream)
Acupuncture
Chiropractic
Physical therapy and magnet therapy
Yoga
Tai chi

Exercise

Exercise to strengthen, stretch, and relax muscles around affected joints is almost always included in a treatment plan for OA. Several studies support the value of exercise for people with OA. One recent study, for example, found that people with OA of the knee who participated in a home exercise program experienced a 23% reduction

in pain compared with only 6% reduction in people who did not exercise. Other studies also suggest that in addition to reduction of pain and disability, exercise improves strength, range of motion, balance and coordination, endurance, and posture.

Medications

The most common type of medication used to treat osteoarthritis are nonsteroidal, anti-inflammatory drugs (NSAIDs). They are common pain relievers that reduce pain and swelling. Types include aspirin, ibuprofen (Motrin, Advil, Nuprin), and naproxen (Aleve, Naprosyn, Naprelan, Anaprox). Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers and bleeding. In April 2005, the FDA asked drug manufacturers

of NSAIDs to include a warning label on their product that alerts users of an increased risk for cardiovascular

events and gastrointestinal bleeding.

Other medications used to treat OA include:

COX-2 inhibitors (coxibs). Coxibs block an inflammation-promoting enzyme called COX-2. This class

of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the

U.S. market following reports of heart attacks in some patients taking the drugs. Celecoxib (Celebrex) was still available at the time of this report, but labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Patients should ask their doctor whether the drug is appropriate and safe for them.

Steroids. These medications are injected directly into the joint. They may also be used to reduce

inflammation and pain.

Artificial joint fluid (Synvisc, Hyalgan). These medications can be injected into the knee. They

may temporary relief pain for up to 6 months.

Nutrition and Dietary Supplements

Glucosamine

Glucosamine, a natural compound found in all body tissues, is the fundamental building block required for the synthesis of glycosaminoglycans and proteoglycans. Furthermore, glucosamine is a rate-limiting precursor for the synthesis of hyaluronic acid, the backbone of proteoglycans and the major organic constituent of synovial fluid. As a component of these macromolecules, glucosamine plays an important role in the synthesis of the cartilage matrix and other tissues. Classified as a chondroprotective agent, supplemental glucosamine functions

to promote the synthesis of the substrates required for healthy cartilage matrix and to enhance the functional

ability of the joints.1,4,9 Continued use is required to maintain benefits.

Chondroitin Sulfate

Chondroitin Sulfate is a major class of glycosaminoglycans that are required for the formation of proteoglycans; and as such, they are essential for the structural and functional integrity of the joint.6-10 The mechanism of action of supplemental chondroitin sulfate is likely similar in nature to that of glucosamine, since it also provides substrates for proteoglycan synthesis. As a chondroprotective agent, it has a metabolic effect as well; its action

is to inhibit many of the degradative enzymes that break down the cartilage matrix.1,9

Glucosamine and Chondroitin

Supplemental glucosamine and chondroitin sulfate may stimulate the synthesis of proteoglycans by chondrocytes, inhibit the degradation of proteoglycans, and enhance lubrication of the joints, thereby promoting healthy joint cartilage structure and function.1,4,8,9 Three capsules provide 1500 mg of glucosamine and 1200 mg of chondroitin sulfate. Research suggests that daily supplementation at this level is safe and effective for long-term use.2-5

Methyl-sulfonyl-methane (MSM)

MSM is a naturally occurring sulfur compound. Sulfur, the fourth most abundant mineral in the human body (behind calcium, phosphorus, and magnesium), is essential for the normal functioning of the body's growth and repair mechanisms.12

MSM is most often used to relieve muscle and joint pain. It has been used for this purpose in veterinary medicine since the early 1980's.

Experts believe MSM stops pain impulses before they reach the brain, acting as an analgesic and an anti- inflammatory. The sulfur in MSM plays a role in the formation of keratin (an essential protein for skin, hair, and nail growth) and collagen (a protein that supports healthy skin and flexible joints). Sulfur also helps the body produce immunoglobulins, which are important for normal immune function.

S-adenosylmethionine (SAMe)

Laboratory and animal studies suggest that SAMe may reduce pain and inflammation to a similar degree as NSAIDs, but with fewer side effects. Researchers are still investigating how this works. Clinical studies with humans (although generally small in size and of short duration) have also shown favorable results for SAMe when used to relieve OA symptoms.

In several short-term studies (ranging from 4 to 12 weeks), SAMe supplements (1200 mg/day) compared favorably

to NSAIDs in adults with knee, hip, or spine osteoarthritis in the following ways:

Diminished morning stiffness
Decreased pain
Reduced swelling
Improved range of motion
Increased walking pace

In an extensive review of studies conducted with SAMe (collectively representing over 20,000 people), including trials of up to two years, the supplement was associated with the following benefits:

Improved symptoms
Fewer side effects
No negative influences on cartilage production (unlike NSAIDs)
Reduced risk for relapse

Vitamin D

Vitamin D is essential to bone and cartilage health. Studies evaluating vitamin D use for OA have found the following:

Vitamin D prevents breakdown of cartilage
Lower intake of vitamin D may be linked to greater risk of hip OA in older women and OA-related joint changes (visible on X-rays) in both men and women

Antioxidants

Antioxidants appear to significantly ease oxidative stress and inflammation caused by free radicals and may slow the progression of OA. Free radicals can be produced in the joints and have been implicated in many degenerative changes in the aging body, including destruction of cartilage and connective tissue. Antioxidants appear to offset the damage caused by free radicals. Although further evidence is needed to substantiate these claims, studies of groups of people observed over time suggest that the following antioxidants may help reduce the symptoms of OA:

Vitamin A and beta-carotene
Vitamin C
Vitamin E

In addition, extensive research on vitamin E has revealed that people with OA experienced a significant reduction in pain after taking 600 mg of vitamin E per day, compared with those who received placebo. Those who took 600 mg

of vitamin E three times a day experienced significantly less pain than those who took the NSAID diclofenac.

Niacinamide

In one preliminary study, 72 patients with OA were randomly assigned to receive niacinamide, a form of vitamin

B3, or placebo. Participants in the niacinamide group experienced a 30% improvement in symptoms compared

to a 10% worsening of symptoms experienced by those in the placebo group. People taking niacinamide reported the following:

Improved joint mobility
Reduced need for anti-inflammatory medications

The study authors speculate that niacinamide may aid cartilage repair. It does appear, however, that niacinamide must be used for at least 3 weeks before the patient will experience benefits. Experts also suggest that long-term use (1 to 3 years) may slow the progression of the disease.

Omega-3 Fatty Acids

Omega-3 fatty acids are found in coldwater fatty fish (such as salmon, mackerel, and herring), flaxseed, rapeseed, and walnuts. Research regarding the use of omega-3 fatty acid or fish oil supplements for inflammatory joint conditions has focused almost entirely on rheumatoid arthritis. Based on laboratory studies, however, many researchers suggest that diets rich in omega-3 fatty acids (and low in omega-6 fatty acids) may benefit people with other inflammatory disorders, including OA. In fact, several laboratory studies of cartilage-containing cells have found that omega-3 fatty acids decrease inflammation and reduce the activity of enzymes that break down cartilage. Patients also showed increased improvement when fish oil supplements were used in combination with olive oil.

Another potential source of omega-3 fatty acids is the New Zealand green lipped mussel (Perna canaliculus ), used for centuries by the Maori people for good health. In a trial involving 38 people with OA, nearly 40% of those who received P. canaliculus extracts experienced the following:

Decreased joint stiffness and pain
Increased grip strength
Enhanced walking pace

ETArolTM is a cold-processed proprietary extract of New Zealand green-lipped mussels and contains essential fatty acids called eicosatetraenoic acids (ETAs). These ETA's play a key role in the reduction of joint swelling due to arthritis. Studies show that ETA oils from sea mussels are more effective at reducing inflammation than aspirin or ibuprofen.

In addition to the Omega-3 fatty acids (ETA's), ETArolTM also contains naturally chelated minerals, vitamins, nucleic acids (RNA and DNA), glucosamine, chondroitin, and glycosaminoglycans. Glycosaminoglycans (GAG's), which are long, unbranched chains of complex sugar, are the principle components of cartilage and synovial fluid found in the joints.

There are nine principle classes of GAG's. It has been published that glucosamine and chondroitin contain only two of the nine classes of GAG's. In contrast, ETArolTM contains all nine of these principle classes, which

enhances the reversal of the arthritic process and provides all the building blocks necessary to rebuild damaged

cartilage.

Manganese

Manganese is among the substances that the body needs to build cartilage. In a clinical trial studying glucosamine, chondroitin, and manganese, 72 people with mild to moderate OA of the knee showed significant improvement

in symptoms after taking these supplements in combination compared to those taking placebo. No serious side effects were reported. People with more severe forms of the disease did not show improvement as a result of taking the combination, however. Although earlier studies have indicated that low levels of manganese may contribute

to degenerative joint conditions and bone loss, it is not clear from this trial what role manganese (as opposed to chondroitin and glucosamine) may have played in the results. Interestingly, an estimated 37% of Americans have low levels of manganese in their diets.

Herbs

Herbal remedies are among the most popular alternative therapies used by individuals with arthritis. Scientific evidence suggests that the following herbs are most effective for treating OA:

Devil's claw (Harpagophytum procumbens)
Willow bark (Salix spp.)
Stinging nettle (Urtica dioica)
A combination of aspen (Populus tremula), ash (Fraxinus excelsior), and goldenrod (Solidago viraurea)
An Ayurvedic herbal mixture containing extracts of ashwagandha (Withania somnifera), boswellia

(Boswellia serrata), and turmeric (Curcuma longa)

A combination of willow bark (Salix spp.), black cohosh (Cimicifuga racemosa), sarsaparilla (Smilax spp.), guaiacum (Guaiacum officinale) resin, and poplar bark (Populus tremuloides )

Other herbs that have shown promise in the treatment of OA include:

Capsaicin (Capsicum frutescens)

Capsaicin is the main component in hot chili peppers (also known as cayenne). Applied to the surface of the skin, it is believed to deplete stores of a substance that contributes to inflammation and pain in arthritis. Several studies have shown that capsaicin cream provided much better pain relief than a placebo but no improvement

in joint swelling, grip strength, or function for people with OA. Pain reduction generally begins 3 to 7 days after

applying the capsaicin cream to the skin.

Avocado/Soybean extracts

Laboratory studies suggest that avocado/soybean extracts stimulate the growth of collagen (the principal protein

of the skin, tendons, cartilage, and bone) in cartilage cells. In a study of 164 people with OA of the knee or hip, researchers found that participants who received avocado/soybean extracts for 6 months experienced the following improvements with few or no side effects:

Reduction in pain and disability
Increase in mobility
Reduced need for NSAIDs

The revised edition of The Arthritis Cure by Dr. Jason Theodosakis lists ASU along with glucosamine and chondroitin

as the three nutrients essential to his program.

Suggested Nutritional Supplementation

Light to Moderate:

Kaprex® - 1 softgel twice daily
Non-responders by day 5 move to 3 softgels daily
Time to benefit: Immediate to 10 days.

Kaprex is a clinically tested herbal dietary supplement that provides natural joint relief that is easy on the gastrointestinal (GI) tract. It works by interfering with signals in the body that initiate the production of damaging compounds that cause minor pain and negatively impact cartilage and other joint tissues.

Chondro-Relief Intensive CareTM - 2 capsules twice daily

Chondro-Relief Intensive Care is a comprehensive joint nutrition formula designed to support healthy joint function by featuring Glucosamine HCI, Chondroitin Sulfate, Methyl-Sulfonyl-Methane (MSM),

P. Canaliculus, Hyaluronic Acid, and Avocado/Soybean Unsaponifiables (ASU) in addition to other

antioxidants that support healthy connective tissue.

Moderate to Severe:

UltraInflamX® Plus 360 - 2 scoops twice daily. Medical food for inflammation and biotransformation
Follow the Anti-Inflammatory Diet
Chondro-Relief Intensive CareTM - 2 capsules twice daily

Chondro-Relief Intensive Care is a comprehensive joint nutrition formula designed to support healthy joint function by featuring Glucosamine HCI, Chondroitin Sulfate, Methyl-Sulfonyl-Methane (MSM),

P. Canaliculus, Hyaluronic Acid, and Avocado/Soybean Unsaponifiables (ASU) in addition to other antioxidants that support healthy connective tissue.

EPA-DHA 6:1TM Enteric Coated - 2 softgels three times daily.

EPA-DHA 6:1 Enteric Coated omega 3 fatty acids providing a ratio appropriate for patients with chronic inflammatory conditions.

Iso D3TM - 1 tablet three times daily.

Iso D3 delivers 2,000 IU of Vitamin D

with Isoflavones that may help facilitate the body's utilization of

vitamin D3 for enhanced health benefits.

If there is a soy sensitivity use:

D3 1000TM - 2 microtablets three times daily. Bioactive Vitamin D in a microtablet delivery form

Adjunctive Modalities

Acupuncture

Several controlled trials suggest that the ancient Chinese practice of acupuncture is an effective treatment for pain associated with OA, as well as for other aspects of the condition, including diminished joint function and reduced walking ability. In fact, a few studies have shown that people with OA experience better pain relief and improvement in function from acupuncture than from NSAIDs such as aspiroxicam. In a 6 month study of 570 participants funded by the National Institutes of Heath (NIH), researchers found that patients who received true acupuncture had a 40% increase in function, which is significantly better than those receiving the sham procedure. Another study of 300 people with OA found that after 8 weeks of treatment, pain and joint function improved more with acupuncture than with minimal acupuncture or no acupuncture in patients with OA of the knee.

The NIH is funding a large multi-center clinical trial due to be completed in 2001 to fully evaluate efficacy and safety of acupuncture for OA.

Chiropractic

Although there is no evidence that chiropractic care can reverse the joint degeneration that causes OA, some

studies indicate that spinal manipulation may:

Increase range of motion
Restore normal movement of the spine
Relax the muscles
Improve joint coordination
Reduce pain

In fact, a comprehensive review of the scientific literature suggests that chiropractic, especially when combined with glucosamine supplements and rehabilitative stretches and exercise, is an effective supplemental treatment

for OA. Chiropractors will avoid using direct thrusts or pressure on red, swollen joints.

Physical Therapy

Physical therapy can be useful to improve muscle strength and the motion at stiff joints. Therapists have many

techniques for treating OA.

Manual therapy and supervised exercise may decrease or delay the need for surgery in individuals with OA. In

a trial evaluating physical therapy and exercise in people with OA of the knee, participants who received manual therapy to the lumbar spine, hip, ankle, and knees showed the following improvements:

Less stiffness
Reduced pain
Improved functional ability
Improved walking distance
Less need for knee surgery 1 year later

If therapy does not make you feel better after 3 to 6 weeks, then it likely will not work at all.

Balneotherapy (Hydrotherapy or spa therapy)

Balneotherapy is one of the oldest forms of therapy for pain relief for people with arthritis. The term "balneo" comes from the Latin word for bath (balneum) and refers to bathing in thermal or mineral waters. Sulfur-containing mud baths, for example, have been shown to relieve symptoms of arthritis. However, hydrotherapy, which can be performed under the guidance of certain physical therapists, is occasionally used interchangeably with the word balneotherapy. The goals of balneotherapy for arthritis include:

Improving range of joint motion
Increasing muscle strength
Eliminating muscle spasm
Enhancing functional mobility
Easing pain

Although balneotherapy is most often used for psoriatic or rheumatoid arthritis, some medical experts believe that it may be beneficial for OA as well.

Ice Massage, Transcutaneous Nerve Stimulation (TENS), and Electroacupuncture

In a well-designed trial comparing the effectiveness of TENS, electroacupuncture, and ice massage for the treatment of knee OA, each of these methods were found to:

Reduce pain at rest
Reduce stiffness
Boost walking speed
Increase quadriceps muscle strength
Increase knee range of motion

TENS is a technique used by many physical therapists. When the nerve stimulation of TENS is applied to

acupuncture points, it is called electroacupuncture.

Mind/Body Medicine

Chronic pain and disability can make daily functioning difficult. A holistic approach to care in these clinical circumstances may positively affect both lifestyle and how one feels overall. Many people report that relaxation techniques, such as guided imagery and meditation, are an important part of comprehensive, holistic care, and help to alleviate pain and other symptoms of OA.

Yoga

This ancient Indian practice is well known for its physical, psychological, emotional, and spiritual benefits and is often recommended in the West to relieve musculoskeletal symptoms. In one clinical trial studying OA of the hand, the group practicing yoga showed significant decrease in pain and improved range of motion compared to those participating in non-yoga stretching and strengthening sessions. Certain yoga "asanas" (postures) strengthen the quadriceps and emphasize stretching, both of which benefit people with OA of the knee. People with arthritis should begin asanas slowly and they should be performed only after a warm up. Yoga is best performed under the careful guidance of a reputable instructor.

Herbal Remedies

Two recent trials comparing Ayurvedic herbal remedies with placebo found that participants who consumed the Ayurvedic herbs experienced significant improvement (with only mild side effects) compared to those in the placebo group. An Ayurvedic combination containing the following herbs significantly reduced pain and disability

in people with OA:

Winter cherry (Withania somnifera)
Boswellia (Boswellia serrata)
Turmeric (Curcuma longa )

Tai Chi

This ancient form of classical conditioning practiced in China for centuries has been shown to produce a number

of benefits, including the following:

Improved fitness
Increased muscular strength
Enhanced flexibility
Reduced percentage of body fat
Diminished risk of falls in the elderly

In a trial of subjects with OA of the knee or hip (ranging in age from 49 to 81), those who practiced tai chi twice a week for three months showed significant improvement compared to those in the control group in the following areas:

Overall sense of quality of life
Diminished feelings of stress/tension
Increased satisfaction with general health
Decreased fatigue
Easier self management of arthritis symptoms

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