Nutritional Fundamentals for Health

 
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Select Treatments for Osteoarthritis in Women

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Osteoarthritis (OA) is the most common form of arthritis and women have much higher rates than men. Women face a quadruple threat for osteoarthritis: hormones, biology, a genetic predisposition and more recently, obesity.

About 60% of the 27 million individuals in the U.S. that have arthritis are women. Prior to age 55, more men tend to have arthritis but after age 55, women catch up and then surpass the number of men.

Biologically, women's tendons are more elastic causing the joints to have more motion and the pelvis is wider, putting more stress on the knees. Hormonally, estrogen protects cartilage (the cushion between the joints) from inflammation and then after menopause the estrogen declines naturally, leaving the cartilage more vulnerable to inflammation and thus degeneration. Genetics also play a role in osteoarthritis with the disease running in families and a particular genetic link in women and even at the same locations as their mother. In more recent years, obesity statistics show that more women than men are obese or severely obese. Extra body weight puts more stress on the joints with increasing pressure on the cartilage and faster wear. More abdominal fat puts more pressure on the lower joints.

All this is to say that we need many tools to prevent and treat osteoarthritis. One tool is the use of botanicals and one of the most studied botanicals for osteoarthritis is Turmeric.

Curcumin+ Boswellia for OA in knees
In this study published in early 2018, a curcumin product was compared to curcumin plus boswellia and compared to placebo. A curcumin 500 mg capsule, containing 333 mg curcuminoids was given three times daily for 12 weeks to one group. Another group was given a 500 mg capsule three times daily containing 330 mg curcuminoids and 150 mg boswellic acid, also for 12 weeks. A third group received placebo. Research participants had osteoarthritis of the knees.[1]

Both preparations, whether curcumin alone or the curcumin-boswellia combination was favorable compared to placebo after only 3 months of continuous use, in men and women with osteoarthritis of the knees. The combination produced was significant compared to placebo in both physical performance tests and pain and function scores including morning stiffness, limited function and disease severity while the curcumin only product was superior to placebo in physical performance tests only.[1] 

Commentary: Curcumin results from many clinical studies, animal studies and in vitro studies demonstrate beneficial effects in treating chronic inflammation. The ability to effect inflammation is through various enzymes, transcription factors, growth factors, cytokines and other genes. Curcumin appears to be the most studied botanical for it's anti-inflammatory and disease modulating effects on osteoarthritis. Rheumatoid arthritis has also been improved by curcumin in at least one clinical trial. The results of the current study showed that after 12 weeks of use of a curcuminoid product or in combination with boswellic acid, improvement in pain related symptoms and function can be improved although the combination of the two plants is more effective.

Turmeric for Arthritic Joint Pains - A Review 
All the randomized clinical trials of turmeric rhizome and components of turmeric for treating arthritis symptoms of the joints were evaluated in this systematic review. Numerous databases were included up through April 2016.[2]

A final eight randomized clinical trials met the criteria in which six were done in the Middle East and Asia, one in the US, and one in Italy. Four of the trials were classified as moderate quality and four were of high quality.[2]

A variety of turmeric products were used in the different studies including ethanolic extracts, a water extract, and curcumin/curcuminoid-rich extracts. One study compared turmeric to placebo, glucosamine, and turmeric plus glucosamine. Another compared turmeric to diclofenac and diclofenac plus turmeric. Two compared turmeric to placebo, two compared turmeric to ibuprofen, and two compared turmeric plus a positive control to the positive control alone. Doses ranged from 500 - 1,500 mg/day, and studies varied in duration from four weeks to four months.[2]

The pain visual analogue scale (PVAS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores were the main measures used for the meta-analysis. The overall PVAS was much lower in the turmeric group than in the placebo groups. The pooled PVAS and WOMAC pain scores were also much lower in the turmeric group than placebo, but the pooled PVAS and WOMAC pain scores between turmeric and ibuprofen or diclofenac or glucosamine were not significantly different, which suggests that turmeric was at least comparable to the benefits of those treatments.

Three of the studies demonstrated a decline in the frequency of pain medication. In two of the trials, the distance walked over six minutes, the pain on walking (whether level or stairs), and time spent walking were similar between curcumin and ibuprofen. Subscales in functional joint changes were lower in turmeric than placebo in two trials, and performance was increased with turmeric compared with glucosamine in one trial.

Commentary: I'm familiar with reading numerous individual studies on turmeric compounds and the effects on joint pains, but this systematic review and meta-analysis found evidence that 8-12 weeks of about 1,000 mg/day of turmeric standardized extract can reduce arthritis symptoms that are similar to the improvements seen with ibuprofen and diclofenac. Because one of the randomized clinical trials used curcumin-free turmeric polysaccharides and found benefit superior to chondroitin sulfate, it brings up the question as to whether other analgesic/anti-inflammatory components of turmeric, other than curcuminoids, are also involved in this therapeutic effect. The studies included in this review were of small sample size from 45-124 individuals, and there were vast differences in the turmeric preparations used; but none the less, the results continue to point to sufficient evidence that at least we should be trying turmeric products for arthritic joint pains.

Topical Lavender Oil Massage for Knee Osteoarthritis Pain Relief
This study conducted in Iran in individuals 18-65 years included those with confirmed osteoarthritis of the knee and a pain level of 4 or higher on a visual analogue scale (VAS). Patients were randomly assigned to the lavender oil massage, placebo, or control group with 30 in each. The patients applied lavender essential oil in almond oil, or the almond oil only, or no massage. Those in the lavender oil group massaged their knees for 20 minutes with 5 ml of lavender essential oil that was diluted in the almond oil. The same 20 minutes of massage instruction were given to the almond oil only group. This was done nine times within a three-week time frame.[3]

When rating pain, a 0 indicated no pain and 10 represented the worst pain the patient could imagine. Pain scores were collected at baseline, at the end of the three-week intervention, and at one and four weeks after the end of the treatment period.[3]

After the three weeks of intervention, the mean score of severity of pain in the lavender essential oil group had significantly improved compared with baseline and compared with both the placebo and control group. At one week after the end of the intervention, the pain severity score in the lavender essential oil group was significantly improved compared with the control group only and at four weeks, the differences between the groups was not significant.[3]

Commentary: The first thing I encountered when I recommended this treatment to a patient this week, was that she found it challenging to imagine a 20 minute massage to her knees either delivered by herself or her husband. That makes me think that next time, I might ask someone to just rub it in for 3-5 minutes. They can still leave the knees uncovered to receive any actual aromatherapy benefit. But I do not know if this tactic will be effective. It is a simple, safe, and reasonably affordable self-care too, although lavender essential oil is not always inexpensive.

Flavonoid Mixture and Osteoarthritis of the Knee
A proprietary mixture of flavonoids (baicalin and catechin), known as flavocoxid (Limbrel) was tested against naproxen, a conventional nonsteroidal anti-inflammatory drug (NSAID) for the management of moderate osteoarthritis of the knees. A four-week, multicenter, double-blind, controlled pilot study was conducted in patients who had grade 2 to 3 of a knee. Subjects were randomly assigned to either flavocoxid 500 mg twice daily or naproxen 500 mg twice daily. One hundred and three individuals were randomized to the trial. Two failed to complete the study, both in the naproxen arm, and one presumably due to side effects of upper gastrointestinal discomfort.[4]

Both the flavocoxid and naproxen groups showed significant and similar reduction in the signs and symptoms of knee osteoarthritis (p< 0.001) of approximately 85% from baseline for all four measurements. There were no statistically significant differences in the two groups with respect to any of the measurable outcomes.[4]

A 30-day therapeutic trial of an herbal product demonstrating similar results to a common pharmaceutical analgesic with an average 85% improvement in signs and symptoms of knee osteoarthritis is a great sign for practitioners and patients.[4] 

Seaweed Supplement for Knee Osteoarthritis 
This small, double-blind, placebo-controlled pilot study investigated a supplement from seaweed (Aquamin) on symptoms of moderate to severe OA of the knees in 22 subjects. Measurements assessed included walking distance, range of motion, pain and joint mobility of the knee in those individuals who were withdrawing from non-steroidal anti-inflammatory drugs. Eight subjects were given 2400 mg/day of Aquamin and 14 were given placebo for up to 12 weeks.[5]

Fourteen individuals completed the study and analysis showed that there were no significant differences in pain and joint mobility scores but did show small but statistically significant improvements in passive and active extension, and improved walking distance in the Aquamin group, but not the placebo group. There was a 50% reduction in NSAID use in the Aquamin group although it should be noted that the Aquamin did not eliminate the NSAID use altogether.[5]

Commentary: Whether it is the calcium, one or more of the other minerals, or a phytonutrient ingredient in the product, this study suggests that Aquamin is a potential treatment for moderate to severe OA of the knee, especially able to reduce the use of NSAIDS, improve walking distance and range of motion.

Pine Bark Extract (Pycnogenol) and Osteoarthritis of the Knee
The purpose of this study was to evaluate the effects of Pycnogenol in reducing symptoms of OA in a double-blind, placebo-controlled, randomized trial. One hundred patients older than age 25 were suffering from mild OA (stage I or II) in at least one knee and mild to moderate pain for at least three months prior to the study, and/or morning knee stiffness and /or knee crepitus.[6] 

The main outcome criteria were reduction of symptoms of OA using the WOMAC scores and reduction of pain using PVAS. The secondary outcome was a decrease in the use of analgesics. Study subjects were randomly assigned to Pycnogenol 50 mg tid or placebo (14 men and 36 women in the Pycnogenol group and 18 men and 32 women in the placebo group). Patients were allowed to continue with their current medication (NSAIDs or analgesics) and were allowed to change medication as needed but were required to report dosage or frequency changes at each visit. Patients were evaluated at baseline, at three months, and four weeks after completing the treatment. The WOMAC questionnaire for pain, stiffness, and daily activities was completed by the patient every two weeks during the study, whereas the PVAS was filled in by each patient weekly.[6] 

The WOMAC-A score, summarizing pain scores, improved significantly in the Pycnogenol group (p=0.0004) over the time of the study. The statistical difference for pain reduction compared to baseline in the Pycnogenol group was evident after weeks 8, 12, and 14 (p < 0.001). The difference between treatment group and placebo was near statistical significance at week 8 (p= 0.08).[6]

The WOMAC-B score, analyzing stiffness, showed statistically significant improvement (p=0.01) in the Pycnogenol groups versus baseline after weeks 8, 12 and 14. Statistically significant differences between treatment group and placebo group were observed at weeks 8 and 12 (p< 0.05).[6] 

The WOMAC score in regards to the ability to perform daily activities improved significantly versus baseline in the Pycnogenol group at weeks 8, 12 and 14 (p< 0.01). The change in the placebo group was not significant, and the difference between the Pycnogenol and placebo groups was not significant.[6] 

Pain scores by PVAS were somewhat higher in the placebo group than the Pycnogenol group at baseline although this difference was not significant. After treatment for four weeks, the treatment group reported less pain when compared to placebo; and pain continued to diminish until month three. The correlation of decreased pain over time was statistically significant (p< 0.04) for the Pycnogenol group, but the correlation was poor for the placebo group (p<0.17). Only a marginal significance was seen between Pycnogenol versus placebo at weeks 4 (p=0.08) and 8 (p=0.07).[6]

Patients in the Pycnogenol group were able to reduce their use of analgesics or NSAIDs at a higher percentage than those in the placebo group. Ten percent of placebo-group patients had to increase their dose of analgesics whereas no higher doses were needed in the Pycnogenol group. Commentary: Other in vitro research has shown that Pycnogenol inhibits other inflammatory cells and specifically inhibits COX1 and COX2. These previously observed anti-inflammatory effects, as a background to the current study, contributes a body of information that enables us to have another viable alternative treatment in early OA of the knee as well as an approach to possibly reduce the use of analgesics and NSAIDs in pain management.

Creatine Helps with Osteoarthritis of the Knees 
This randomized, double-blind, placebo-controlled trial was done to investigate the efficacy of combined creatine supplementation and strengthening exercises in postmenopausal women with OA of the knee. Twenty-six women from 345 volunteers met the inclusion criteria for the trial. These 26 were then randomized to either the creatine or the placebo. Two patients withdrew. Patients were given either a placebo or 20 g/day for one week and then 5 g/day for 11 weeks. All were enrolled in a lower limb resistance training program. Women were assessed at baseline and after 12 weeks of intervention.[7] 

Physical function was the primary outcome, but secondary outcomes included lean mass, quality of life, pain, stiffness, and muscle strength.[7]

Significant improvement in physical function was seen only in the creatine group as well as improvements in stiffness, lower limb lean mass, and quality of life. The placebo group did not demonstrate any significant improvement in these parameters. Both the creatine and placebo group demonstrated significant reductions in pain.[7]

Commentary: Previous results have shown that creatine supplementation can be useful in rehabilitation of immobilized patients on regaining muscle mass, and other positive findings have been reported in patients with inflammatory myopathies such as dermatomyositis and polymyositis, as well as dystrophinopathies such as Duchenne disease. Muscular weakness, lower limb lean mass, and even muscular atrophy are also relevant to those with OA of the knees. Creatine plays a role in muscle contraction, muscle strength, and muscle function while also augmenting lean mass. The current positive study is in contrast to an earlier study that did not demonstrate improvements in recovery after 40 days of creatine supplementation in OA patients post-total knee arthroplasty. Perhaps the lack of exercise training, the shorter supplementation time period, and/or the severity of the disease account for these negative results.

References:
  1. Haroyan A, et al. BMC Complementary and Alternative Medicine 2018; 18:7. 
  2. Daily JW, et al. J Med Food. 2016;19(8):717-729. 
  3. Nasiri A, et al. Complement Ther Clin Pract. 2016;25: 75-80. 
  4. Levy R, et al. Nutrition Research. 2009;29:298-304. 
  5. Frestedt J, Kuskowski M, Zenk J. Nutrition Journal. 2009; 8:7. 
  6. Cisar P, et al. Phytotherapy Research 2008;22:1087-1092. 
  7. Neves M, et al. Medicine and Science in Sports and Exercise. 2011;43:1538-1543.