Conditions:
Osteoarthritis
Principal Proposed Treatments
•
Glucosamine, Chondroitin Sulfate, SAMe (S-Adenosylmethionine), Niacinamide
Other Proposed Treatments
•
Devil's Claw, White Willow, Acupuncture, Healthy Diet, Avocado/Soybean Unsaponifiables, Ginger, Cat's Claw, Proteolytic Enzymes, Boswellia, Turmeric, Yucca, MSM (Methyl Sulfonyl Methane), Beta-Carotene, Boron, Bromelain, Cartilage, Cat's Claw, Chamomile, Copper, Dandelion, Feverfew, Green-Lipped Mussel, Molybdenum, D-Phenylalanine, Selenium, Vitamin C, Vitamin E, Zinc
In osteoarthritis, the cartilage in joints has become damaged, disrupting the smooth gliding motion of the joint surfaces. The result is pain, swelling, and deformity.
The pain of osteoarthritis typically increases with joint use and improves at rest. For reasons that aren't clear, although x rays can find evidence of arthritis, the level of pain and stiffness experienced by people does not match the extent of injury noticed on x rays.
Many theories exist about the causes of osteoarthritis, but we don't really know what causes the disease. Osteoarthritis is often described as "wear and tear" arthritis. However, evidence suggests that this simple explanation is not correct. For example, osteoarthritis frequently develops in many joints at the same time, often symmetrically on both sides of the body, even when there is no reason to believe that equal amounts of wear and tear are present. Another intriguing finding is that osteoarthritis of the knee is commonly (and mysteriously) associated with osteoarthritis of the hand. These factors, as well as others, have led to the suggestion that osteoarthritis may actually be a body-wide disease of the cartilage.
During one's lifetime, cartilage is constantly being turned over by a balance of forces that both break down and rebuild it. One prevailing theory suggests that osteoarthritis may represent a situation in which the degrading forces get out of hand. Some of the proposed natural treatments for osteoarthritis described later may inhibit enzymes that damage cartilage.
When the cartilage damage in osteoarthritis begins, the body responds by building new cartilage. For several years, this compensating effort can keep the joint functioning well. Some of the natural treatments described below appear to work by assisting the body in repairing cartilage. Eventually, however, building forces cannot keep up with destructive ones, and what is called end-stage osteoarthritis develops. This is the familiar picture of pain and impaired joint function.
The conventional medical treatment for osteoarthritis consists mainly of analgesic medications, such as Tylenol, and anti-inflammatory drugs, such as Aleve and Orudis. The main problem with anti-inflammatory drugs is that they can cause ulcers. Another possible problem is that they may actually speed the progression of osteoarthritis by interfering with cartilage repair and promoting cartilage destruction.1–5 In contrast, some of the treatments described below appear to actually slow the course of the disease.
Recently, the use of extracts of cayenne pepper has found its way into conventional medicine. Briefly, it consists of the regular application of cayenne cream to the affected joint, ultimately resulting in a decreased sensation of pain. Unfortunately, this truly natural treatment seldom provides more than modest relief.
Principal Proposed Treatments for Osteoarthritis
There are several very useful natural treatments for osteoarthritis. Not only do they reduce pain without causing any side effects, some may slow the progression of osteoarthritis.
Glucosamine: Safe Pain Relief That Lasts
One of the best-documented alternative approaches to the treatment of osteoarthritis is the supplement glucosamine. Glucosamine is a small molecule formed of a sugar attached to a chemical structure called an amine. Taking glucosamine supplements provides a natural raw material for rebuilding cartilage. It seems to stimulate the activity of cartilage cells and perhaps also protect cartilage from damage.6–13
In Portugal, Spain, and Italy, glucosamine has been a primary treatment for osteoarthritis since the 1980s, and it is also widely used by veterinarians in the United States. Not only can it reduce symptoms, but there is some evidence that it can also slow the progression of osteoarthritis. For this reason it is sometimes called a "chondroprotective" drug ("chondro" refers to cartilage). However, the evidence for such a “disease-modifying” effect is not yet strong. (There is some stronger evidence for chondroitin regarding this issue.)
In the long view, such a benefit would be even more important than relieving symptoms. No conventional treatment for osteoarthritis protects the joints or hinders the progression of the disease.
What Is the Scientific Evidence for Glucosamine?
Reasonably solid studies have found that supplementation with glucosamine sulfate can relieve the pain of osteoarthritis.For example, one recent double-blind study compared the effectiveness of glucosamine sulfate and placebo in 252 people with osteoarthritis of the knee.14 The results showed that after 4 weeks the participants treated with glucosamine sulfate were in less pain and could move better than those given a placebo. No more side effects were noted in the participants who took glucosamine than in those who did not.
Another study found glucosamine equally effective as the standard arthritis drug Feldene.15 A total of 329 participants were given 20 mg of Feldene, glucosamine, a placebo, or glucosamine plus Feldene daily. Improvement was monitored through the Lequesne Index, a rating scale that evaluates the severity of osteoarthritis. Equivalent benefit was seen in all the treated groups. After 90 days, treatment was then stopped, and the participants were followed for an additional 8 weeks.
Interestingly, whereas the benefits of Feldene rapidly disappeared following the end of treatment, glucosamine was still producing a full effect at the end of the post-treatment period.
Other studies, enrolling a total of about 400 participants, have found equivalent benefit between glucosamine and ibuprofen.16,17,18
However, not all studies found benefit. In three studies involving a total of almost 300 individuals, use of glucosamine failed to provide any improvement in symptoms.19,20,99 The explanation for this discrepancy is not clear. The authors of two trials suggest as a possible explanation that glucosamine might be most effective in relatively mild cases of arthritis, while their trials enrolled individuals with fairly severe arthritis.19,99 Further investigation will be necessary to determine if this hypothesis is correct.
Nonetheless, overall, it certainly appears that glucosamine is effective for reducing symptoms of osteoarthritis. In addition, it appears to provide another important benefit: slowing the progression of the disease.
A 3-year, double-blind, placebo-controlled study of 212 individuals suggests that glucosamine can protect joints from further damage.21 Over the course of the study, individuals given glucosamine showed some actual improvement in pain and mobility, while those given placebo worsened steadily. Even more importantly, x rays showed that glucosamine treatment prevented progressive damage to the knee joint.
Finally, a 6-month, double-blind, placebo-controlled study of combined glucosamine, chondroitin, and manganese found evidence of significant improvement in the treated group.22
For more information, including dosage and safety issues, see the full glucosamine article.
Chondroitin Sulfate: Relieves Pain and May Slow Progression of Osteoarthritis
Reasonably good evidence supports the use of chondroitin sulfate for the pain of osteoarthritis as well. In addition, provocative evidence suggests that it may help prevent your arthritis from gradually getting worse.
Like glucosamine, chondroitin plays a natural role in the body's manufacture of cartilage. In Europe, chondroitin sulfate is usually injected directly into arthritic joints (under no circumstances should you try this yourself!). However, in the United States, oral chondroitin sulfate is the most popular form of this supplement.
For years it was questioned whether oral chondroitin sulfate could possibly work. Because of its large molecular size it is difficult to see how chondroitin sulfate could find its way through the lining of the digestive tract to be absorbed into the bloodstream. However, in 1995 researchers found evidence that up to 15% of chondroitin is actually absorbed.32
Scientists are unsure how chondroitin sulfate acts to protect joints, but one of three theories (or all of them) might explain its mode of action. Some evidence suggests that chondroitin may inhibit the enzymes that break down cartilage in the joints.33 Another theory holds that chondroitin sulfate increases the amount of hyaluronic acid in the joints. (Hyaluronic acid is a protective fluid that keeps the joints lubricated.) Finally, as a building block of cartilage, available chondroitin might simply help the body rebuild damaged joints.
Perhaps the most exciting development is the recent evidence that suggests chondroitin sulfate can actually slow the progression of osteoarthritis. This would make it a true chondroprotective drug (see the previous discussion under the heading Glucosamine). However, more research is needed to confirm this potential benefit.
What Is the Scientific Evidence for Chondroitin Sulfate?
Much of the early research on chondroitin sulfate was published in French or Italian journals and has not been translated into English. However, the results of four double-blind placebo-controlled clinical trials were recently published in English. They provide substantial evidence that chondroitin sulfate is an effective treatment for osteoarthritis. Some show evidence that chondroitin sulfate can reduce the symptoms of osteoarthritis, while others suggest that, like glucosamine, it can slow or perhaps even stop the progression of the disease.
Reducing Symptoms
Double-blind, placebo-controlled studies involving a total of several hundred participants suggest that chondroitin can relieve symptoms of osteoarthritis.
One study enrolled 85 people with osteoarthritis of the knee and followed them for 6 months.34 Participants received either 400 mg of chondroitin sulfate twice daily or placebo. At the end of the trial, doctors rated the improvement as good or very good in 69% of those taking chondroitin sulfate but in only 32% of those taking placebo.
Another way of comparing the results is to look at maximum walking speed among participants. Whereas individuals in the chondroitin group were able to improve their walking speed gradually over the course of the trial, walking speed did not improve at all in the placebo group. Additionally, there were improvements in other measures of osteoarthritis, such as pain level, with benefits seen as early as 1 month. This suggests that chondroitin was able to stop the arthritis from gradually getting worse (see also Slowing the Disease).
Good results were seen in a 12-month double-blind trial that compared chondroitin against placebo in 104 individuals with arthritis of the knee,35 as well as in a 12-month trial of 42 participants.36
Benefits were also seen in two short-term trials involving a total of about 240 individuals.37,38
In addition, a 6-month, double-blind, placebo-controlled study of combined glucosamine, chondroitin, and manganese found evidence of significant improvement in the treated group.39
Generally positive results were also seen in other studies, including one that found chondroitin about as effective as the anti-inflammatory drug diclofenac.40,41,42
Slowing the Disease
An important feature of the study of 42 individuals mentioned previously was that the individuals taking a placebo showed progressive joint damage over the year, but among those taking chondroitin sulfate no worsening of the joints was seen.43 In other words, chondroitin sulfate seemed to protect the joints of osteoarthritis sufferers from further damage.
A longer and larger double-blind placebo-controlled trial also found evidence that chondroitin sulfate can slow the progression of osteoarthritis.44 One hundred and nineteen people were enrolled in this study, which lasted a full 3 years. Thirty-four of the participants received 1,200 mg of chondroitin sulfate per day; the rest received placebo. Over the course of the study researchers took x rays to determine how many joints had progressed to a severe stage.
During the 3 years of the study only 8.8% of those who took chondroitin sulfate developed severely damaged joints, whereas almost 30% of those who took placebo progressed to this extent.
Unfortunately, the report did not state whether this difference was statistically significant.
Slowing of disease progression was also seen in the 1-year study of 104 individuals described previously.45
Additional evidence comes from animal studies. Researchers measured the effects of chondroitin sulfate (administered both orally and via injection directly into the muscle) in rabbits, in which cartilage damage had been induced in one knee by the injection of an enzyme.46 After 84 days of treatment, the damaged knees in the animals that had been given chondroitin sulfate had significantly more cartilage left than the knees of the untreated animals. Taking chondroitin sulfate by mouth was as effective as taking it through an injection.
Looking at the sum of the evidence, it does appear that chondroitin sulfate may actually protect joints from damage in osteoarthritis. However, at the present time, the evidence cannot be regarded as conclusive.
For more information, including dosage and safety issues, see the full chondroitin article.
SAMe: Helpful, but Very Expensive
SAMe (S-adenosylmethionine) is a substance that occurs naturally in the body and plays a role in numerous biochemical functions. When used for osteoarthritis, it appears to reduce pain, decrease swelling, and improve mobility about as effectively as standard anti-inflammatory drugs, with significantly fewer side effects and risks. Indirect evidence suggests that SAMe may slow the progression of osteoarthritis, but we have no direct evidence that SAMe offers this benefit. At present, this is an extremely expensive supplement.
What Is the Scientific Evidence for SAMe?
A substantial body of scientific evidence supports the use of SAMe in arthritis.50Numerous double-blind studies involving over a thousand participants in total suggest that it is approximately as effective as standard anti-inflammatory drugs.
One of the best double-blind studies enrolled 732 patients and followed them for 4 weeks.51 Over this period, 235 of the participants received 1,200 mg of SAMe per day, while a similar number took either placebo or 750 mg daily of the standard drug naproxen. The majority of these patients had experienced moderate symptoms of osteoarthritis of either the knee or of the hip for an average of 6 years.
The results indicate that SAMe provided as much pain-relieving effect as naproxen and that both treatments were significantly better than placebo. However, differences did exist between the two treatments. Naproxen worked more quickly, producing readily apparent benefits at the 2-week follow-up, whereas the full effect of SAMe was not apparent until 4 weeks. By the end of the study, both treatments were producing the same level of benefit.
Animal evidence suggests that SAMe may help protect cartilage from damage.52,53
For more information, including dosage and safety issues, see the full SAMe article.
Niacinamide
There is some evidence that vitamin B3 in the form of niacinamide may provide some benefits for those with osteoarthritis. In a double-blind study, 72 individuals with arthritis were given either 3,000 mg daily of niacinamide (in 6 equal doses) or placebo for 12 weeks.64 The results showed that treated participants experienced a 29% improvement in symptoms, whereas those given placebo worsened by 10%. For more information, including dosage and safety issues, see the full vitamin B3 article.
Other Proposed Treatments for Osteoarthritis
Devil's Claw: Reduces Arthritis Pain
Several preliminary double-blind studies involving a total of over 300 people suggest that the herb devil's claw can soothe the pain of various types of arthritis.65,66
For more information, including dosage and safety issues, see the full devil's claw article.
White Willow: Natural Aspirin
The herb white willow contains the aspirin-like substance salicin. A 2-week double-blind placebo-controlled trial of 78 individuals with arthritis found evidence that willow extracts can relieve osteoarthritis pain.69
Aspirin and related anti-inflammatory drugs are notorious for irritating or damaging the stomach. However willow appears to be gentler in this regard.70,71
For more information, including dosage and safety issues, see the full white willow article.
Acupuncture: Might Be Helpful
A single-blind controlled trial of 67 individuals with osteoarthritis of the hip found that acupuncture significantly improved symptoms, with relief enduring for months after the end of treatment.72
Another study compared electroacupuncture, ice massage, TENS (an electrical method related to acupuncture), and placebo therapy in 100 individuals with arthritis of the knee.73 The results showed that all three methods, given 5 times weekly for 2 weeks, produced superior results to placebo.
However, a review of previous studies identified five single- or double-blind trials comparing acupuncture to sham acupuncture in osteoarthritis.74 Of these, all but one failed to find acupuncture effective.
For example, a 3-week double-blind trial evaluated 40 individuals with osteoarthritis of the knee.75 After 3 weeks of treatments 3 times daily, the results were negative: true acupuncture was no more effective than sham acupuncture.
Acupuncture for osteoarthritis has also been compared to anti-inflammatory drugs, steroid injections, and diazepam (Valium), with mixed results.76,77,78
Healthy Diet: Can Slow the Progression of Arthritis
Observational studies indicate that diets high in vitamin C, vitamin E, and beta-carotene are associated with significantly slower progression of osteoarthritis (as much as 70%).79 These nutrients are found in fruits, vegetables, whole grains, nuts, and seeds.
However, these findings say little about the potential benefits of vitamin C, vitamin E, and beta-carotene supplements. When you get vitamins from foods you also get numerous other healthful substances. In any case, observational studies are unreliable as guidelines to treatment. Only double-blind trials can establish the effectiveness of treatments, and there is no supporting evidence from double-blind trials to turn to.
Other Herbs and Supplements
Special extracts of avocado and soybeans called avocado/soybean unsaponifiables (ASU) have been investigated as a treatment for osteoarthritis.85–92 In a double-blind trial, 260 individuals with arthritis of the knee were given either placebo or ASU at 300 or 600 mg daily.93 The results over 3 months showed that use of ASU significantly improved arthritis symptoms as compared to placebo. There was no significant difference seen between the two doses tested.
A 6-week, double-blind, placebo controlled study of 247 individuals with osteoarthritis of the knee evaluated a combination herbal product containing ginger and the Asian spice galanga (Alpinia galanga).94 The results showed that participants in the ginger/galanga group improved to a significantly greater extent than those receiving placebo. However, despite news reports claiming that this study proves ginger effective for osteoarthritis, it only provides information on the effectiveness of the herbal combination. A previous, though much smaller, study of ginger alone failed to find meaningful evidence that it worked..95
A four week, double-blind, placebo-controlled trial of 45 individuals suggests that the herb cat’s claw may be helpful for the treatment of osteoarthritis.100
Preliminary double-blind comparative studies suggest that proteolytic enzymes might be useful for osteoarthritis.97,98
One small double-blind study suggests that direct application of stinging nettle leaf to a painful joint may improve symptoms.80
Weak evidence suggests that the herbs boswellia, turmeric, yucca, and the supplement MSM might be useful for osteoarthritis. (See the articles on these topics for more information.) A double-blind crossover trial of 42 individuals with osteoarthritis found that treatment with an herbal combination containing ashwagandha, boswellia, turmeric, and zinc significantly reduced symptoms over a 3-month period as compared to placebo.81
Evidence from animal studies suggests that green-lipped mussel may help alleviate osteoarthritis symptoms.82,83,84 Other herbs and supplements sometimes recommended for osteoarthritis include beta-carotene, boron, bromelain, cartilage, cat's claw, chamomile, copper, dandelion, feverfew, molybdenum, D-phenylalanine, selenium, vitamin C and zinc. However, there is little to no evidence as yet that these treatments are effective.
Although vitamin E is sometimes recommended for the treatment ofosteoarthritis, a six-month double-blind placebo-controlled trial of 77 individuals with osteoarthritis found that treatment with vitamin E at dose of 500 IU daily failed to provide any benefit as compared to placebo.96
View References
Last reviewed August 2002 by Medical Review Board
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