Tag Archives: osteoarthritis

Review Not Favorable to Herbs for Osteoarthritis

Patients with osteoarthritis who routinely turn to devil’s claw, Indian frankincense, ginger, and other herbal medicines for symptom relief may want to think twice about this practice.

Image via Flickr user anolobb by Creative Commons License

According to a review of these products that appears in the January 2012 issue of Drug and Therapeutics Bulletin, a publication of the London-based BMJ Group, there is little conclusive evidence to justify their widespread use by patients with the disease (DTB 2012: 50:8-12). A press release about the review points out that few robust studies on the use of herbal medicines for osteoarthritis have been carried out. “And those that have frequently contain design flaws and limitations, such as variations in the chemical make-up of the same herb, all of which comprise the validity of the findings.”

Herbal medicines commonly used to treat osteoarthritis includes vegetable extracts of avocado or soybean oils (ASUs), cat’s claw, devil’s claw, Indian frankincense, ginger, rosehip, turmeric and willow bark. According to the review, the best available clinical evidence suggests that ASUs, Indian frankincense, and rosehip may work, “but more robust data are needed.”

Some herbal medicines may cause adverse reactions in patients taking other medicines and prescription drugs. For example, chronic use of nettle can interfere with drugs used to treat diabetes, lower blood pressure, and depress the central nervous system while willow bark can cause digestive symptoms and renal problems.

The review characterized the use of herbal medicines for osteoarthritis as “generally under-researched, and information on potentially significant herb-drug interactions is limited.”

Although the UK Medicines and Healthcare products Regulatory Agency has approved Traditional Herbal Registrations for several herbal medicinal products containing devil’s claw for rheumatic symptoms, “the trial results for this herb are equivocal,” the review states. “There is little conclusive evidence of benefit from other herbs commonly used for symptoms of osteoarthritis, such as cat’s claw, ginger, nettle, turmeric and willow bark. Healthcare professionals should routinely ask patients with osteoarthritis if they are taking any herbal products.”

The review did not include data on glucosamine and chondroitin sulfate.

— Doug Brunk (on Twitter@dougbrunk)

Photo courtesy anolobb’s photostream

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Osteoarthritis: Disease or Late-Life Benchmark?

Osteoarthritis is a well-accepted diagnosis among physicians for a painful and stiff joint, but the other day I spoke with a rheumatologist who has a very different take on how to characterize these symptoms.

image courtesy Flickr user Jeff Rasansky

Dr. Nortin M. Hadler, a professor of medicine at the University of North Carolina, Chapel Hill, insisted on calling the condition “regional joint pain.” Calling it osteoarthritis reflected the over-medicalization that modern industrialized society imposes on ubiquitous conditions that shouldn’t really qualify as bona fide disorders, he said.

Dr. Hadler’s contention is that having a joint or two grow painful and less functional over the course of more than half a lifetime was inevitable for most people, as unavoidable as “headache and heartache,” he told me. “There is no person after midlife who does not have substantial regional joint pain,” and the older they get the more this colors their life. “It is abnormal [for a middle-aged or elderly person] to go a year without important back pain, or to go 3 years without important knee pain,” he said.

Dr. Hadler added that when people seek out medical care for such routine aches and pains of aging, there is really something else going on in the patient’s life. “The regional disorder can be viewed as a surrogate complaint,” he said. A patient might say “My knee is hurting,” but the reality is that their complaint reflects a broader difficulty they’re having.

He described a study he ran that compared two sets of similar elderly people with the same complaint of knee pain. One group had sought medical care, the other hadn’t. What also distinguished the two groups were their levels of loneliness and depression, which were both higher among those who went to see a physician, he said.

Removing osteoarthritis from the category of pathology and reclassifying it as a more benign and routine part of aging would, no doubt, come as a surprise to many physicians who specialize in studying and treating it.  Last September, I covered the annual meeting of the Osteoarthritis Reasearch Society International (OARSI) and, in counterpoint to Dr. Hadler’s contention, this meeting was attended by hundreds of experts and specialists who would be happy to detail the pathophysiologic processes that appear to define osteoarthritis. Back then, I posted an entry on this blog on the intriguing hypothesis that joint trauma (a severely twisted knee, for example) sets off an acute inflammatory cascade that can have profound long-term consequences for joint health and osteoarthritis development. This notion raises the possibility that a quick and potent anti-inflammatory intervention could help prevent or attenuate the longer-term irreversible damage, the same way that prompt treatment of a myocardial infarction can limit damage to the heart.

My guess is that the reality falls somewhere in between. I’m sure Dr. Hadler is right about some people. Their joint pain is really not too disabling and is something that many other people would just work through, but because of an overlay of coincident emotional and psychiatric issues, they seek medical care and in many cases find physicians who are willing, as Dr. Hadler puts it, to medicalize life and “create a society of the walking wounded.”

On the other hand, I also believe that as the result of some unusual trauma or bad genetics a person can develop a deteriorated and painful joint that is truly pathologic and outside the scope of normal wear and tear and really needs medical attention.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Osteoarthritis Pain Assessment Poses Challenges

  What is pain, and how much is too much?

Patients with painful hip or knee osteoarthritis say they know how much pain they should have to make joint replacement surgery necessary, and that their physicians are largely in the dark about their pain. Patients use the Supreme Court’s famous approach to identifying pain that warrants knee surgery: I know it when I feel it.

courtesy Flickr user GlobinMedChiro

To get the perspective of osteoarthritis patients, Dr. Gillian Hawker, a Toronto rheumatologist, and her associates put 58 local patients with moderately severe hip or knee osteoarthritis in focus groups, including 36 veterans of total joint replacement surgery. They discussed joint surgery appropriateness, and the point when appropriateness and their willingness to have the surgery intersect. The major determinant was their pain: their ability to cope with it, and its impact on their quality of life.

Patients “evaluated their pain against some invisible marker,” and despite having what they called high levels of pain they often said it was not bad enough to justify surgery, Dr. Hawker reported last month at the World Congress on Osteoarthritis. As one focus-group patient put it, “I don’t feel I’m ready.” But when their pain became bad enough, they said it trumped all other considerations of whether or not to have joint surgery. Most patients in the focus groups also said their pain had been “inadequately evaluated” by their physicians.

Other study results reported at the Congress also highlighted the highly subjective and variable nature of knee pain. Dr. Tuhina Neogi from Boston University measured central sensitization in knee osteoarthritis patients, and saw that both increased disease severity and duration significantly boosted the incidence of central sensitization, a neurologic process that alters the nervous system and potentially increases pain sensitivity.

Dr. Neogi and her associates found the only way to reliably measure central sensitization was by comparing pain in a patient’s knee affected by osteoarthritis and in the patient’s second, unaffected knee. Comparisons between different patients involved too much variable noise to show a significant link between osteoarthritis and central sensitization. Comparing knees within individual patients cut away the effects of genetics, and psychosocial and cultural factors, allowing each patient to apply their own unique, personal criteria for judging pain severity. 

—Mitchel Zoler (on Twitter @mitchelzoler)

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Treating Knee Injury Like a Myocardial Infarction

  When a skier skids on an icy patch, torques her knee, and gets a sudden ligament tear, is it the orthopedic equivalent of a myocardial infarction? Can rapid medical treatment in the knee damp down the resulting inflammatory, pathologic cascade and help preserve the knee’s long-term health, the same way that rapid restoration of coronary blood flow limits the extent of a myocardial infarct and long-term loss of cardiac function?

image courtesy Flickir user Dance Party Duo

 It’s an intriguing concept, and forms the rationale behind a new approach to acute management of traumatically injured knees that is starting clinical testing.

 “The early phase of acute joint injury represents a window of opportunity to promote healing and prevent a subsequent cascade of joint destructive processes,” said Duke rheumatologist Virginia Byers Kraus last week at the World Congress on Osteoarthritis in Brussels.

 “We think of osteoarthritis as a slow, chronic disease,” but that’s when it appears years after a traumatic knee injury, she said. “This is a curable type of osteoarthritis because you know when it starts. We should start to treat joint injury emergently, like an acute myocardial infarction.”

 At the Congress, she presented early evidence supporting this approach. A single, knee-joint injection of a potent anti-inflammatory drug, the interleukin 1 receptor antagonist anakinra, produced dramatic improvements in short-term pain and function when administered roughly 2 weeks after traumatic injury in a pilot controlled study with 11 patients. The next step is to look at more patients, and to push the time of treatment even earlier, within a few hours after injury, Dr. Kraus said.

 The time seems ripe for finding new ways to manage knee injuries, as middle-aged and elderly Americans are experiencing an epidemic of knee osteoarthritis that needs the ultimate treatment, total knee replacement. A second report at the Congress documented that the rate of total knee replacement surgeries soared during the decade ending in 2007. The number of knee replacements in Americans aged 45-64 tripled in that period, reaching 221,000 in 2007, with all U.S. knee replacements in 2007 reaching an all-time, 1-year high of 550,000.

 —Mitchel Zoler (on Twitter @mitchelzoler)

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