18 January 2010

Stayin' Alive : Managing Osteoarthritis with Complementary and Alternative Medicine

"Skeleton Woman." Prisma color pencil, watercolor, applique by Lucy Madeline

Stayin' Alive:
Hanging out in the joints with osteoarthritis

By Mariann G. Wizard / The Rag Blog / January 19, 2010

[Stayin' Alive is a new periodic column on Complementary and Alternative Medicine by Rag Blogger Mariann G. Wizard, a professional science writer with a wide-ranging knowledge of natural health therapies. Readers may suggest topics for future columns, within the restrictions suggested below, in the Comments section of The Rag Blog.]

Osteoarthritis (OA) is a collective name for several degenerative processes in the body’s moveable joints, most often the hips, knees, feet, shoulders, or hands/wrists/fingers. OA incidence rises with age, and after about 50, affects more women than men. It causes chronic, often intense pain, reduces flexibility and strength in affected joints, and can discourage healthy exercise.

OA has several causes, including some that are hereditary, and it takes a multi-faceted approach to prevent or slow its progress. As usual, “use it or lose it”; healthy weight-bearing exercise is the best weapon against OA! Other sensible health practices are also beneficial, e.g., lower weight helps knee, foot, and hip OA; take a load off!

Rheumatoid arthritis (RA) is a different condition, and I'm not taking it on today -- maybe in a future column!

Conventional Western or modern medicine isn’t very successful with chronic illnesses, and dissatisfaction with this lack of success helps fuel use of complementary and alternative medicine (CAM). Conventional OA care includes over-the-counter (OTC) and prescription (Rx) pain relievers, e.g., non-steroidal anti-inflammatory drugs (NSAIDs). OTC NSAIDs (e.g., aspirin, ibuprofen, naproxen sodium) relieve pain but can have serious side effects. Rx NSAIDs, such as Celebrex®, can have even worse effects; similar drugs have been withdrawn due to their dangers.

There is also a vast array of Rx pain relievers about which I know very little, except what friends with severe OA and/or RA tell me. Please do not make any changes in your Rx medications, or begin using any herbal medicines (HMs), without discussing fully with your treating physician! I'll have more to say about this later, and what, maybe, some natural therapies can offer even those who really struggle with OA.

One formerly-CAM treatment, injection of hyaluronic acid into affected joints to improve lubrication, is now widely used by mainstream physicians, though with scant evidence it helps.

Hip and knee OA, if they are too debilitating, are treated conventionally with joint replacement surgery -- much more sophisticated than it was in its early years! -- and everyone I know personally who’s had this surgery has been pleased with the results. My Mom had both knees replaced after being diagnosed with cancer; it greatly improved her remaining five years. However, all surgery has risks. Also, today's replacements have an expected lifetime of only 15-20 years, so it makes sense to postpone replacement as long as possible, and not have to do it again later!

I have OA, starting in a broken toe in 1970 ("my weather toe") and spreading to knees (too much rock'n'roll), wrists and hands (too much keyboard) over time. I used OTC pain relievers for years, but became concerned because of potential stomach and/or liver damage from sustained use.

I then used an Rx pain reliever, with near-disastrous results. Since then, I've been exploring CAM's OA options personally, as well as continuing to read and report on the science behind them. I want to use OA here to show the breadth of CAM treatments for one very common condition, and some of their strengths and weaknesses, as an overall introduction to CAM.

If you've read my column before, you may recall my definition of CAM, but here it is again:

CAM is all health practices developed over the course of human history, everywhere in the world, before the discovery of microbes, and many developed since then outside of “Western” medical practice.

Prevention and treatment: Dietary supplements

Dietary supplements (DSs) can help maintain healthy levels of vitamins, minerals, amino acids, and other compounds in the body. I'll write more about nutrition, the modern food supply, and DSs in the future. For right now, it's enough to know that I consider HMs as very specialized DSs, and will talk about them separately. Unless otherwise noted, DSs, taken as recommended, shouldn't interfere with Rx or OTC medications or other conventional therapies. Over time, they may reduce the need for pain relievers, or slow the progress of disease.

Glucosamine and chondroitin, together and separately, have the most evidence for preserving and perhaps increasing cartilage in joints, the “padding” that keeps bone from rubbing on bone. Cartilage is invisible in X-rays, but OA is diagnosed by the decrease in inter-joint (articular) space as cartilage is lost to wear and tear, and to aging.

Inter-joint space in my knees increased when, after arthroscopic surgery for a torn cartilage in one of them in 1997, I began using both glucosamine and chondroitin, and has held steady ever since. I have much less pain, less often, and more flexibility in my knees than I did before starting them, and no serious problems with other joints. Both compounds have good safety records.

Glucosamine is essential for joint lubrication. It is found in all living things. Chondroitin is a related compound. Neither occurs in the usual human diet. Supplements are made from shellfish exoskeletons, and should be avoided by anyone with shellfish allergies. It takes several months to begin to notice the benefit, and you have to keep taking the supplements; for me, it's worth it!

S-adenosylmethionine (SAM-e), a natural compound produced by all organisms, decreases with age. SAM-e helps maintain joint health. It's also used for mood support and healthy liver activity. Methylsulfonylmethane (MSM) works with SAM-e and glucosamine for healthy cartilage. MSM is found in meats, fruits, and vegetables, but we metabolize it less efficiently with age, making supplementation desirable.

Essential fatty acid (EFA) intake is vital for joint lubrication and much more. Omega-3 and omega-6 EFAs (found, e.g., in hempseed oil, flaxseed oil, algae, and fish oil) must be obtained from diet, the body can’t produce them. Chances are excellent you don't eat enough EFAs. Supplementation can be recommended for almost anyone, it has so many benefits. It may cause temporary bowel looseness, but overall, improves regularity.

Osteoporosis contributes to OA through bone loss in joints. While elderly women are especially at risk, men and young women are not exempt. Bone health is complex, but everyone needs calcium and vitamin D to maintain strong bones. Supplements for menopausal women often have other bone-nourishing components, such as plant estrogen isoflavones from soy, red clover, kudzu, or other legumes.

Phytoestrogen use by women with elevated risk of estrogen-sensitive cancer is controversial, and probably best avoided. Also, phytoestrogens may interact with Rx medicines; I simply don't know enough about all the synthetic drugs out there to feel comfortable saying phytoestrogen use is OK for everyone! I will say that bone-conserving pharmaceutical products marketed in recent years have some of the scariest potential side effects of any drugs advertised on teevee; far better to keep your bones strong; again with good basic nutrition, weight-bearing exercise, and, if needed, DSs.

BTW, the preferred form of calcium these days seems to be calcium citrate, absorbable in the human digestive tract. Apparently, the ground-up oyster shell tablets I sucked down for years don't do much good; that calcium isn't in a form our bodies can use!

Treatment: Pain relief

Many CAM treatments for pain have strong evidence of benefit. Massage; aromatherapy; warm-to-hot therapeutic compresses, baths or showers; yoga; and meditation all may be used to good effect. Pepper salves are effective “counter-irritants”; that is, they produce such an intense burning sensation that joint pain becomes irrelevant! (This isn’t as awful as it sounds; OA pain may worsen in cold weather, and is often felt as a cold ache and stiffness, with pain on movement. Heat can feel wonderful, relaxing muscles and boosting blood circulation.)

OTC “heat” products use the same principle, as does the traditional Chinese salve Tiger Balm®. However, effectiveness of counter-irritants is generally short-term. One friend who has severe arthritis used a "TENS" device successfully -- delivering rapid, minute electrical shocks to himself -- for a while. Acupuncture also helped him temporarily, but it, too, is more suited, in my opinion, to relief of acute pain rather than chronic.

For those who prefer HMs, cat’s claw has thousands of years of human use for OA in South America, but has been little studied. It is not an NSAID; its means of action is not understood. I have personally used cat’s claw -- with the DSs mentioned above! -- for my OA, and find it to be one of the faster-acting herbs. If I miss taking it for a few days, my right thumb reminds me; after a few days of resuming use, I no longer notice my OA. It seems to be very safe, with no side effects except, perhaps, some bowel looseness; it goes away.

Cat’s claw isn't very expensive; however, there are concerns about sustainability due to increasing demand. The root bark is used; not a very sustainable harvesting method. I wonder if it would grow in Texas? Cat's claw hasn't been studied in conjunction with Rx or OTC pain medications, and again, I would hesitate to recommend an HM to anyone using such products. I started using cat's claw after a severe allergic reaction to a prescribed NSAID left me unable to use any NSAID, even aspirin; this was about the same time the above-mentioned thumb first began flaring with OA pain.

In general, if an HM is effective, it has the possibility of interacting with other medicines. If you think herbs are "safe" because they are "natural"; please, get a clue! Many perfectly "natural" substances can kill you deader than a dodo! Over 90% of existing synthetic pharmaceutical drugs are based on individual, "active" plant molecules from HMs.

Another HM pain remedy now legal for residents of 14 states, but not yet under the Lone Star, is Cannabis sativa, sweet Mary Jane. In British and U.S. studies of intractable chronic nerve pain -- pain unrelieved except by massive doses of morphine -- and multiple sclerosis (MS), ganja allowed patients to separate themselves mentally from their pain for a while.

Senseless continued prohibition of this valuable HM will soon be challenged by the pharmaceutical companies' desire to cash in on the “pot of gold." Bayer Health, for example, has an investigational new drug (IND) permit in the U.S. for Sativex®, a whole-cannabis extract in a mucosal spray, from British GW Pharmaceuticals. Sativex is already approved in England and Canada for MS.

An IND is a first step in approval for U.S. Rx drugs. If a whole-herb extract is permitted nationally, patients outside medical marijuana states will have a powerful argument for their use of the actual whole herb. Marijuana hasn't been clinically studied in OA, but is widely used for symptomatic relief.

Now, to be perfectly clear, I'm talking about ingesting marijuana! I've heard of using cannabis topically, in hot water compresses, but hey, what a waste! Tetrahydrocannabinol (THC), the main active ingredient in marijuana, isn't soluble in water, but in fats and oils. So, there's no evident way a hot water weed compress would bring any more relief than that obtainable less expensively from a wet towel. I expect somebody will tell me they've used the spent vegetable matter from making "electric butter" as a pain compress with fabulous results; maybe so, but did they also eat the brownies?

If you have surgery -- for any reason, not only joint replacement -- stop using all HMs and DSs (except any you and your doctors agree on) two or three weeks in advance. Some can interfere with blood clotting, effects of anesthesia, and/or post-surgical pain meds.

Other measures

OA is one of the most widespread chronic diseases in the world, and I’ve only scratched the surface of CAMs available. Purely dietary measures, such as eating only anti-inflammatory foods, can be very useful. For example, if you're an adult, stop drinking animal milk! Cheese, yogurt, kefir, etc., are all better for you.

There are many anti-inflammatory HMs with laboratory evidence, CAM usage, and not enough human clinical trials. Trace elements? People with higher intake of dietary boron seldom have arthritis. Shark cartilage, as a DS, is being tested for its effects by the U.S. National Institutes of Health (NIH), one of only a small number of DSs the NIH found had enough preliminary clinical evidence to qualify for government-funded study. Hundreds of Chinese, Indian, and African traditional OA CAMs are used with apparent success, especially by patients from corresponding backgrounds.

Some widely-promoted OA "cures" have been pretty well discredited, among them dimethyl sulfoxide (DMSO), a commercial solvent that penetrates the skin readily and is used as a carrier vehicle for a few human and veterinary medicines. Unfortunately, claims of arthritis relief from DMSO may have been due to the undisclosed inclusion of other pain relievers; also, animal studies found that DMSO use damages the eye lens.

DMSO cannot, however, be described as either a conventional or CAM therapy; it was a scam, pure and simple, because arthritis is a pain, and conventional medicine offers only limited "management" options and no cure. DMSO had no record of thousands of years of human use; no documentation by any reliable source; was not a plant-derived molecule. But many thousands of people tried it because they felt they had nothing to lose.

If you’re too young and healthy to have OA, you’re not too young to prevent it! Healthy weight, basic dietary intake, weight-bearing exercise, and mindfulness are your first lines of defense. Mindfulness includes, for example, being careful about surfaces for running, dancing, and other high-impact activities (firm but resilient is best), making sure you have good arch and ankle support in your shoes, and generally giving your joints a little support so they can support you later in life. Abused joints are weak points OA is likely to attack.

Walking can help prevent hip and knee OA, and benefit OA sufferers as well. I use musical weighted Chinese exercise balls to keep my hands and fingers limber. Whatever you do, keep moving!

Next time: Choosing a health care provider.

Previously: Stayin' Alive: Towards a conscious self-health-care continuum.

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