Painful Obstruction Bi (rheumatological) Syndromes are said to be due to Exterior/Interior pathogenic Wind, Cold, Damp and/or Heat which obstruct the channels and collaterals/vessels causing blockage of Qi and Blood circulation. Bi syndromes manifest as pain, soreness, aches, numbness or heaviness of muscles, sinews, and joints, and/or swelling and burning pain. In general, Painful Obstruction can be divided into four main categories:
Herbal and acupuncture medicine can be very helpful in the treatment of articular and soft tissue rheumatological disorders. The following are basic patterns seen clinically. The treatment of pain in TCM is predicated basically on the saying "if there is free flow there is no pain." Therefore, formulas that restore flow are used. In general, therapies that can unblock flow and thus treat pain incorporate one or more of the following herbal categories (deficiency of Qi and Blood may also lead to obstruction).
The following is a general discussion on the treatment of Blood stasis as it pertains to Sprain/Strains as well as other musculoskeletal Painful Obstruction disorders. Blood stasis is in the opinion of this author the most important aspect in treating Painful Obstruction (especially in chronic patients). In clinical practice there are generally three main levels or degrees of eliminating Blood stasis. If too strong a method is chosen not only may this cause hemorrhaging (theoretically), but also it is said to waste or injure the Blood, Yin and fluids.
Bleeding in musculoskeletal disorders are generally associated with trauma. Trauma and stasis of Blood can result in transformative Heat. It is therefore common to add some cooling herbs when treating acute traumatic injuries. To treat Bleeding there are five major methods.
Carbonizing (charring) an herb strengthens its hemestatic function. Care must be used when using hemestatics as they may cause Blood stasis.
In musculoskeletal disorders:
As Qi and Blood are interdependent and the body’s resistance to strains is dependent, in part, on the condition of the True Qi and Blood, therefore Blood stasis may, and often does effect Qi and Organ functions. Loss of harmony of Qi and Blood may manifest with Organ symptoms and signs (usually at the weakest Organ). When the Liver is affected the patient’s pain may be more susceptible to emotional states, there may be increased depression and agitation, fatigue, numbness, changes in the nails, more severe muscle tension and spasm and subcostal and rib-side tension/sensitivity and/or pain. When the Heart is affected there may be exaggeration of symptomatolagy, insomnia, increased dreaming, palpitations, difficulty in memory and cognitive functioning, and epigastric tension/sensitivity. If the Qi and Blood of the Spleen/Stomach are disharmonious the patients limbs may become weak and atrophy, there may be loss of appetite, loose or sticky stools, abdominal distention especially after eating and periumbilical pulsations. If the Kidneys are affected there may be low back soreness/weakness, weakness and/or pain of lower extremities and knees, aggravation of symptoms by exertion, urinary symptoms, tinnitus, fear, anxiety and lower abdominal pulsations. If the Lungs are affected then one may see symptoms relating to respiration and/or failure of fluids to descend and reach the Kidneys with of shortness of breath, cough, phlegm, and tension/sensitivity of the chest and upper back muscles.
Therefore, for optimal treatment of sprains, strains and Painful Obstruction one should take a good history and treat the patient holistically.
Representing clinical approaches and formulas to the treatment Blood stasis and its complication in patients with musculoskeletal disorders are:
The above formulas are often modified using herbs for Qi stagnation, spicy releasing, Wind dispaling, warming, and dampness resulving.
Qi is often stagnant is patient that suffer from pain and from life stresses. Commonly used Qi moving herbs in musculoskeletal pain are: Radix Linderae Strychnifoliae (Wu Yao), Lignum Aquilariae (Chen Xiang), and Flos Rosae Rugosae (Mei Gui Hua) as well as Radix Curcumae (Yu Jin), and Rhizoma Corydalis (Yan Hu Suo) which moves the Qi within the Blood.
For retrograde flow of Qi with nausea/vomiting/hiccups/ belching and sometimes for swelling: Haematitum (Dai Zhe Shi), Pericarpium Citri Reticulatae (Qing Pi), Fructus Immaturus Citri Aurantii (Zhi Shi), and Calyx Diospyri Kaki (Shi Di) can be used.
Spicy Exterior Releasing
Spicy Exterior releasing herbs are used mainly for Exterior syndromes. Commonly used Spicy warm Exterior releasing herbs for musculoskeletal pain are: Ramulus Cinnamomi Cassiae (Gui Zhi), Radix Ledeboriella (Fang Feng), Rhizoma et Radix Notopterygii (Qiang Huo), Radix Angelicae Dahuricae (Bai Zhi), and Herba cum Radix Asari (Xi Xin).
Spicy cool Exterior releasing herbs for musculoskeletal pain are: Fructus Viticis (Man Jing Zi), and Radix Puerariae (Ge Gen).
The spicy character of these herbs also moves Qi and are used often to warm the channels and assist in moving Qi Blood and stopping pain.
Wind can be due to Exterior or Interior causes. Interior Wind can arise from deficiency of Yin/Blood or excess stagnation transformative Heat. Commonly used Wind extinguishing herbs for musculoskeletal pain are: Rhizoma Gastrodiae Elatae (Tian Ma), Lumbricus (Di Long), Buthus Martensi (Quan Xie), Scolopendra (Wu Gong), and Bombys Batryticatus (Jiang Can). They are used often in patients with muscle spasms, headaches and deep seated obstructions (because of their penetrating qualities).
Articular and soft tissue syndromes often are said to be variations of Wind-Damp Obstruction. Patients may suffer from joint pains that increase with changing weather, especially rainy days. When there is predominance of Wind, there would be migrating joint pains. Since it is said, "to treat Wind first treat Blood" it is common to add Blood herbs to Painful Obstruction formulas. Depending on the patient constitution, Organ health, pathogenic factors and anatomical variations, symptoms and signs can vary. A patient with Wind-Damp pathogens may show a thick white tongue coat. Other patients may have a swollen tongue with thin white coat. The pulse may be slow, slippery, wiry, or soft.
Phytotherapy: Juan Bi Tang (Remove Painful Obstruction).
When there is a predominance of Cold the pain can be more severe and may affect the low back and lower extremities (although any joint can be affected). The pain improves with warmth. The tissues feel tight and the joints are stiff (because of the tightening affect of Cold pathogen). There is usually little or no swelling. Wind-Damp-Cold is seen often with arthrosis.
For severe pain add: Zanthoxylum Netidom (Ye Di Jin Niu) 30g
For joint swelling add: Rhizoma Artisaematis (Tian Nan Xing) 3g, Semen Coicie (Yi Yi Ren) 30g
This pattern may be seen in patients with joint and soft tissue pains and symptoms of Wind-Cold-Damp, but signs such as tongue, lips, eyes, or pulse showing Interior Heat. These are patients with Exterior Bi syndromes and Excess Heat internally. Often Heat is lodged in the Large Intestines, Stomach due to dietary habits or from Liver, Gall Bladder, stagnant Qi and transformative Heat. It can also be seen in patients with Yin deficient constitutions. The joints and soft tissues are not red, hot or particularly swollen. The patient bowels and urine may show signs of Heat. There may be mouth sores and thirst. There may be hidden pathogens with Exterior Wind-Damp-Cold, especially in patients with weak immune systems (Yin/Yang deficiency weak Defensive/antipathogenic Qi). The tongue body may be red and dry and possibly with yellow or off-white coat. The pulse may be rapid, over-flowing, slippery or tidal or may be deep and forceful. This pattern is said also to develop from warm and dry formulas, and/or pharmaceutical drugs (particularly steroids).
This pattern is seen often in patient with chronic painful arthralgias. The pain patterns are mixed, showing characteristics of Wind-Damp-Cold and Blood stasis Qi stagnation. Often the patients show signs of deficiency as well. Since chronic disease result often in Blood stasis and since it is said "to treat Wind first treat Blood" it is common to add Blood moving herbs to Painful Obstruction formulas, especially if traumatic or due to chronic disease—with or/wout signs of Blood stasis (i.e. pulse tongue signs). Because Qi moves the Blood and Qi and Blood are mutually dependent, herbs that regulate Qi are added as well. It is important to remember that this pattern may be seen in patients with or without clear symptoms and signs of Blood stasis. This type of formula can be used in patients with Painful Obstruction (Bi) syndrome that have not responded to Wind-Damp obstruction formulas and/or chronic Cold type formulas.
This pattern is seen often when puffy swelling, numbness, tremors, and possibly itchiness is predominant. Phlegm usually results from constitutional weakness of the Spleen/pancreas or from dietary irregularities which damage the digestive energy of the Spleen and Stomach. Phlegm can also arise from Heat or Cold that congeals fluids, from Qi stagnation that fails to move fluids. Phlegm obstruction can block Nutritive Qi and Blood with resulting numbness and swelling. Other symptoms such as light headedness, dizziness, vertigo, chest discomfort, or nausea may or not be seen. The tongue may be dark and swollen and coat may be greasy. The pulse may be wiry, slippery, or soft.
Phytotherapy: Ban Xia Bai Zhu Tian Ma Tang.
This pattern is seen in patients with morning pain or with posain. Soon after the patient gets up from bed, and moves the affected joint (as warmth and nourishment return to tissues), the pain disappears until the next morning or until a posture is again maintained for a prolonged period. Often the patient can perform most of daily activities pain free—as commonly seen in self reducing disc with morning low back pain. The patient may or not show other symptoms of Qi stagnation and Cold.
Phytotherapy: Modified Xiao Huo Luo Dan.
This pattern may be seen in patient that have active inflammation. The joints may be worm, swollen and stiff. Patients often complain of pain that is severe. The pulse may be rapid and soft or rapid and slippery or wiry. The tongue may be red and have off-white or yellow greasy coat.
Phytotherapy: Early stages - Xuan bi tang (Disband Painful Obstruction Decoction). The following modification can be used.
When Damp-Heat is chronic or severe and there is muscle spasms during strain of the affected joints (during weight bearing and often relaxation when joint not stressed i.e. involetary protective spasm), a modification of Si Miao Wand (Four-Marvel Pill) can be used. This formula can be used for lumbar or lower extremity disorders. The author often uses variations of the formula below for patients with radiculopathy from disc disease. Some patients do well when Xiao Huo Luo Dan is given at the same time.
Modified Si Miao Wand:
For symptoms of muscle spasms add: bai hua she 5g, wu gong 3g, quan xie 4g, mu gua 9g, di gu pi 20g
This pattern is seen often in patients with Rheumatoid and other chronic inflammatory type arthritis. The joints are swollen, red, painful and possibly deformed. The pulse and tongue may or may not show signs of Heat and Dampness. A variation of Two-Marvel Powder (Er Miao San) can be used.
For acute flar take out: Radix Ligustici (Chuan Xiang) 6g, Radix Angelicae Dahuricae (Bai Zhi) 9g, Cortex Cinnamomi (Gui Pi) 6g
Add: Gypsum (Shi Gao) 25g, Flos Loncerae (Jin Yin Hua) 12g, Fructus Forsythiae (Lian Qiao) 9g, Ramulus Cinnamomin (Gui Zhi) 9g
For Joint deformities, spasms and chronic disease take out: Cortex Cinnamomi (Gui Pi) 6g, Radix Gentianae (Long Dan Cao) 12g, Flos Carthami (Hong Hua) 6, Radix Angelicae Dahuricae (Bai Zhi) 9g, Herba cum Radix Asari (Xi Xin) 6g
Add: Radix Paeoniae Rubrae (Chi Shao) 9g: Radix Paeoniae Alba (Bai Shao) 20g, Angelica Sinesis (Dang Gui) 15g, Agkistrodon (Bai Hua She) 5g, Scolopendra (Wu Gong) 3g, Buthus Martensi (Quan Xie) 4g, Eupolyphaga seu Opisthoplatia (Tu Bie Chong) 4g, Herba Epimedii (Yin Yang Hou) 9g, Rhizoma Frynari (Gu Sui Bu) 12g, Radix Polygonum Multiflorum (He Shao Wu) 12g
Commonly used points are: Sedation techniques/bleeding GV-14, 10, UB-17, Sp-10, 9, LI-11, 4, Well (distal-nail) points. Use cupping/bleeding at UB-43 and over swollen areas. Tonify St-36, Sp-6, CV-4, UB-20.
This pattern is seen most often in elderly patients or in patients with chronic arthrosis. The main symptoms are cold pain in the back and knees and stiff joints. Some patients may complain of a sense of numbness/ache and feeling fatigue or heaviness. The pain improves with heat and may worsen in changing weather. The joints and soft tissues are cold and not particularly swollen. The pulse may be weak (deep, fine, soft, thready) or hidden (not obvious, very deep). The tongue may be pale. The representative formula is Du Huo Ji Shen Tong. The following modification can be used:
For severe pain add: Zanthoxylum Netidom (Ye Di Jin Niu) 30g
For Swelling add: Yi Yi Ren 20g, Bi Xie 12g
Commonly used points are: Sedation technique LI-4, TW-5, UB-12, 13. Tonification and Moxa at St-36, Sp-6, K-3, 7, GV-4, CV-4, 6, UB-20, 18, 23, GV-14.
Many natural therapies have been evaluated in the treatment of arthritis. A review article on natural therapies by Pizzorno (1985) suggested that dietary and other natural interventions might be helpful for both inflammatory and non-inflammatory arthritis. A few of the more popular therapies are reviewed here:
Chondroitin Sulfate. Chondroitin Sulfate has been compared to nonsteroidal anti-inflammatory (NSAIDs) in a randomized, multicenter, double-blind study using 400-mg chondroitin sulfate three times per day. Patients treated with NSAIDs had rapid and plain reduction of clinical symptoms, which reappeared after the end of the treatment. In the chondroitin sulfate group however, the therapeutic response appeared later in time but lasted up to 3 months after the end of treatment. Chondroitin sulfate treated osteoarthritis patients had a slow but gradual increase in activity, and these benefits lasted after the end of treatment (Morreale, Manopulo, Galati, et al 1996).
Glucosamine Sulfate. Glucosamine sulfate stimulates cartilage regeneration, protects against joint destruction, and alleviates the symptoms of knee osteoarthritis. Glucosamine sulfate is not an analgesic and takes several weeks before a symptomatic relief can be obtained. Glucosamine sulfate has been shown to help knee arthritis when injected (Reichelt, Forster, Fischer, et al 1994) and when taken orally (Lopes Vaz 1982).
Glycosaminoglycan. Glycosaminoglycan (GAGPS) injections into the knee in a double-blind, placebo-controlled trial showed immediate decrease in the pain after the injections of 43% with the GAGPS and 33% with the placebo. Pain relief in the GAGPS versus the placebo was not different at other intervals. At 6 weeks the Lequesne Index decreased 20% after the GAGPS and 9% after the placebo. At 10 weeks the Lequesne Index decreased 24% after the GAGPS and 13% after the placebo. The decrease in the Lequesne Index at 13 weeks was 31% after the GAGPS and 15% after the placebo. Other measured parameters tended to be more favorably influenced by the GAGPS than placebo. There was minimal side effects which occurred in approximately 8% of the cases (Pavelka, Karel et al 1995).
Ginger. Ginger has been noted in ayurvedic and in OM to be useful in rheumatism. Ginger has been shown in 261 patients with knee osteoarthritis and with moderate to severe pain in randomized double-blind, placebo-controlled, multicenter, parallel group, 6-week study to be helpful. The study showed that ginger extract containing 255 mg and 500-1,500 mg of dried galanga rhizomes given twice daily can result in a reduction in knee pain on standing. Evaluating secondary efficacy variables showed a consistently greater response in the ginger extract group compared with the control group. There was a reduction in knee pain on standing, a reduction in knee pain after walking 50 feet, and a reduction in the Western Ontario and McMaster Universities osteoarthritis composite index that was greater in the ginger group compared with the placebo group. The change in global status and reduction in intake of acetaminophen were greater in the ginger extract group. The subjects who received ginger extract had more gastrointestinal complaints than the placebo group. These GI complaints were mostly mild (Altman and Marcussen 2001).
Ginger has been shown to be helpful also in inflammation and rheumatism in a study of 28 patients with rheumatoid arthritis, 18 with osteoarthritis, and 10 with muscular discomfort using powdered ginger. In the arthritic patients, over 75% had varying degrees of relief from pain and swelling. All the patients with muscular discomfort had pain relief. There were no reported side effects with regards to ginger consumption from 3 months to 2.5 years. Doses ranged from 50 gms of raw fresh ginger daily, to 3 or 4 gms of powdered ginger, per day (Srivastava and Mustafa 1992).
Ginger is known to act as a dual inhibitor of both cyclooxygenase and lipoxygenase and can inhibit leukotriene and prostaglandin synthesis, as well as reduce carrageenan-induced raw-paw edema in animal models of inflammation. Ginger has also been shown in in-vitro studies to inhibit the production of tumor necrosis factor through inhibition of gene expression in human osteoarthritic synoviocytes and chondrocytes (Hamilton 2001).
Sea Cucumber. Sea Cucumber has a reputation in the far east for the management of arthritis. The scientific name is Pseudocolochirus axiologus. The creature contains a multitude of biologically active chemical moieties, one of which is effective against arthritis, and some against cancer— holothurin. The dose is 500mg BID with food (Dorman personal communication).
Capsaicin. The following information comes from a practitioner perspective article by Deal and Chad (1994). Capsaicin is commonly used in the treatment arthritis. Topical capsaicin (extracted from chili papers) may be beneficial in diabetic neuropathy, post herpetic neuralgia, post mastectomy pain syndrome, reflex sympathetic dystrophy and other musculoskeletal pains. Purified capsaicin has its effect on type C- sensory neurons. It depletes substance P, a neurotransmitter of pain, from type C-neurons. Substance P is involved also in the exacerbation of the inflammation of arthritis. When the type C-neurons are repeatedly exposed to purified capsaicin they cease to synthesize, store and release substance P. The pain impulses are diminished. Substance P and prostaglandin PG 2 levels in synovial tissue decrease with regular joint application of topical capsaicin. Patients suitable for capsaicin therapy include those with 1 or 2 painful joints. The 2 strengths of topical capsaicin that are available are .025% and .075%. For most patients with mild to moderate pain .025% strength is a logical place to start. Patients should be instructed to apply a small amount of capsaicin to the skin covering of the effected joint. For example, for a knee, a pea-size dab cream is sufficient. Capsaicin should be applied 3 to 4 times a day. Once pain relief has been established with 4 times a day it may be reduced to 2 times a day depending on pain relief. Patients should be directed to wash their hands thoroughly after applying capsaicin cream because inadvertent transference can cause temporary burning and stinging in the eyes or other sensitive mucous membranes (a roll-on is available). Relief usually occurs within a few days. Adverse effects can be burning and stinging. The burning may be as short lived as 2 to 4 days. It is often worsened after bathing while exercising or perspiring. Topical anesthetics such as lidocaines before application of the cream may reduce burning. The patient should be instructed to continue applications for at least 2 weeks before evaluation of efficacy. No apparent systemic effects including drug-drug-food reactions have been reported.
In this author’s experience the use of capsaicin role-on (which contain also Boswellia serrata and Methyl-sulfonyl-methane or MSM) has been useful in arthrosis, and rheumatoid arthritis of any joint, tendinitis of most tendons including epicondylitis, and in bursitis. Patient compliance however can be problematic due to burning.
Antioxidants. Antioxidant intake may be protective against the progression of osteoarthritis and development of pain, but not in prevention of oseoarthritis. A study that evaluated 640 participants found the incidence and progression of osteoarthritis to occur in 81 and 68 knees respectively. There was no significant association between the incidence of arthritis and any nutrient. There was a 3-fold reduction in the risk of osteoarthritis progression found for both the middle tertile and the highest tertile of vitamin C intake. This related mostly to a reduced risk of cartilage loss. Those with high vitamin C intake also had a reduced risk of developing knee pain. A reduction in the risk of osteoarthritis progression was seen for beta-carotene and vitamin E intake but they were less consistent. A high intake of antioxidant nutrients, particularly vitamin C, may reduce the risk of cartilage loss and disease progression in people with osteoarthritis (McAlindon, Timothy et al 1996).
Hyaluronic Acid. Intra-articular ("purified") hyaluronic acid injections may have a protective effect on cartilage damage in osteoarthritic joints—by the removal of noxious substances from the joint space through the lymphatic system (Ghosh, Peter et al 1995). Interestingly however, a 5 year follow-up study of the relationship between hyaluronic acid and osteoarthritis of the knee showed that higher hyaluronic acid levels were significantly related to disease duration, minimum joint space and previous surgery at entry-baseline of patients studied. The data suggested that hyaluronic acid levels predict disease outcome and osteoarthritis of the knee and confirmed that a serum level of keratin sulfate was not a useful prognostic marker for osteoarthritis (Sharif, Mohammed, et al 1995).
Acetyl Merystoleate. Acetyl merystoleate (CMO) is a product obtained from mice. In the 1970’s Dr Dehl working at NIH discovered that mice do not ordinarily suffer from arthritis and it turned out that they have a metabolic product CMO, which is peculiar to their species. Dr. Dehl has "cured" his own arthritis and that of friends with this product. It seems there are at least three sources of this material with varying degree of purity and as far as Dr. Wright was able to determine in July 1996, the best comes from Dr. Dehl and his daughter. The name they use is Myristin. It is recommended that one capsule be taken twice a day for five days (only) and this may need to be repeated once at the most. Benefit from Myristin has been reported in other health problems including emphysema, chronic bronchitis and hypertension. Other animals, which have been found to contain this substance, are sperm whales, and the anal glands of male beavers (Dorman personal communication).
DMSO. It has also been suggested recently that Acetyl merystoleate (CMO) be applied directly over the affected part of the body with DMSO. The concentration of DMSO in water needs to be balanced carefully. At present 70% seems the optimal. Too high a concentration is apt be hygroscopic and too low a concentration not carry the substance. It has also been found that mineral deficiency contributes to degenerative arthritis, both osteoarthritis and rheumatoid arthritis. The best of both worlds, therefore, seems to add some mineral to the DMSO at the same time. (Vanadium, Chromium, Selenium, Boron and other are included in what has become the Tahoma [Dr. Wright] clinic dispensary’s routine). The capsule of the Myristin oil can be opened, applied to the skin and then rubbed in with "DMSO with minerals." The skin surface needed might be as much as the front of the whole thigh on both sides (Dorman personal communication).
Pulse Electromagnetic Fields. A double-blind pilot study involving 27 patients with osteoarthritis predominantly of the knee were treated with pulsed electromagnetic field which consisted of 18 half-hour periods of exposure to an extremely low frequency (less than 30 Hz). Varied, pulsating electromagnetic fields averaging 10 to 20 gauss of magnetic energy at a coil current of up to 2 amperes. The pulsed phase duration was 67 ms, including 15 micropulses with a pause duration of 0.1 second. These sessions were given at a frequency of 3 to 5 per week and extended over a period of approximately 1 month. Twenty-five of 27 patients completed the study. In patients with active treatment, there was an average improvement of 34% at midpoint, 36% at the end of treatment and 47% 1 month later. The placebo group showed an average improvement of 8% at midpoint, 10% at the end of treatment and 14% 1 month later. There was no toxicity noted. The authors conclude decreased pain and improved functional performance of these patients treated with pulse electromagnetic fields suggests this modality has potential as an effective means of improving symptoms in osteoarthritic patients (Trock, David et al 1993).
Exercise. The Arthritis Foundation states that physical therapy may be the most valuable treatment for the estimated 16 million people in the United States who have osteoarthritis. Systematic reviews and subsequent RCTs have found that both exercise and education may help reduce the burden of pain and disability in people with hip or knee osteoarthritis and had the strongest evidence for any of the non-invasive-chemical interventions. Practitioners should prescribe a low impact exercise program involving keeping the joints flexible, preserving the strength of the muscles on which the joints depend for their stability and protecting diseased joints against further damaging stresses. Those with osteoarthritis may benefit by doing exercise in the morning. Trying to get 10 repetitions is beneficial but if the pain persists they can go down to 5 repetitions. If they have no pain they should work towards 20 repetitions (Hamilton 2001).
Essential Fatty Acids. Greenland Eskimos and the Japanese population have lower incidences of inflammatory disease, which may be related to the consumption of cold-water marine fish. There have been many studies showing the benefit of essential fatty acid supplements in RA patients. Effects of altering dietary essential fatty acids on requirements for non steroidal anti-inflammatory (NSAIDs) drugs in rheumatoid arthritis has been shown (Belch et al 1988). The affect from NSAIDs is mediated through inhibition of cyclo-oxygenase enzymes, thereby decreasing production of the 2 series prostaglandins (PGs). The lipoxygenase enzyme is not affected however, allowing leucotriene (LT) production, e.g., LTB4 (an inflammatory mediator). Treatment with evening primrose oil (EPO) which contains gamma-linolenic acid (GLA) leads to production of the 1 series PGs, e.g., PGEI, which has less inflammatory effects. GLA can inhibit LT production as well. Eicosapentaenoic acid (EPA, fish oil) treatment provides a substrate for PGs and LTs, which are also less inflammatory (Dorman ibid).
A number of studies, including placebo-controlled studies, have shown GLA to be an effective treatment for RA in doses ranging from approximately 500 mg to 6 gm of GLA from borage oil or primrose oil. Fatty acids can regulate cell activation, immune responses, and inflammation. Fatty acid supplementation appears to be well tolerated and is an effective treatment for diseases characterized by acute and chronic inflammation (Rothman, Deborah et al 1995). Omega-3 fatty acids (fish oils) have moderate benefit in RA but much less than Naproxen (NSAID). The positive changes in a vegetarian diet in RA patients appears to be due to changes in the bacterial flora (Kjeldsen-Kragh, Jens 1996).
An in vitro study showed that incorporation of omega-3 fatty acids into articular cartilage chondrocyte membranes results in a dose-dependent reduction in the expression and activity of proteoglycan degrading enzymes and, the expression of inflammation-inducible cytokines and cyclooxygenase-2 (COX-2), but not the constitutively expressed COX-1. Omega-3 fatty acid supplementation can specifically affect regulatory mechanisms involved in chondrocyte gene transcription. Omega-3 fatty acid supplementation can affect molecular mechanisms that regulate the expression of catabolic factors involved in articular cartilage degradation (Curtis, Hughes, et al 2000).
Protease and Peptidase Enzymes. Several studies have appeared so far which refer to the systemic effects of oral proteases and peptidases such as Serratia peptidase (SP). Studies show repression of edema and repression of blood vessel permeability induced by histamine or bradykinin. These enzymes also effect the kallikrein-kinin system and the complement system, thus modifying the inflammatory response. Clinically, SP has been used as an anti-inflammatory agent in the treatment of RA, traumatic injury, and post-operative inflammation, as well as chronic sinusitis to improve the elimination of bronchopulmonary secretions, and to facilitate the therapeutic effect of antibiotics in the treatment of infections. In the urological field, SP has been used successfully for cystitis and epididymitis (Dorman personal communication). Bromelain is a proteolytic enzyme, which comes from the stem of the pineapple plant and has long been used to reduce swelling and inflammation. Bromelain is used at 80-320 mg/day.
Boswellia Serrata. Gum resin extracts of Boswellia serrata have been used in the treatment of RA. The terpenoids and gum resin are potent anti-inflammatory compounds that inhibit 5-lipoxygenase. In evaluating more than 260 individuals with RA, Boswellia extract was found to be effective. Boswellia extract is a disease-modifying agent and can replace other disease-modifying therapies. Early use is beneficial. Therapy is well tolerated and shows high levels of safety for early use and long-term therapy. The long-term effects of Boswellia extracts on the joints and the anatomy however are not yet clear. Dose ranges are three 400 mg tablets 2 or 3 times daily (Etzel 1996).
Feverfew. Tanacetum parthenium or feverfew as been used for RA and other inflammatory diseases. Volatile oils are its chief constituents with sesuiterpene lactones, especially parthenolide being most active (Goenewegen and Knight 1986). Extracts rich in sesuiterpene lactones can produce a dose-dependent inhibition of thromoxane B2 and leukotriene B4 and thus have anti-inflammatory effects (Summer 1992). Feverfew can be prescribed at 25-150 mg/day of dried powdered leaf or 150-250 mg/day of standardized extracts.
Sting Nettle. Sting Nettle or Urtica Dioica flower extract has been shown to inhibit biosynthesis of acrachidonic acid metabolites in vitro. Extracts have shown strong concentration dependent inhibition of cyclooxygenase derived reaction. A phenolic acid isolate from the extract inhibits the synthesis of leukotriene B4 in a concentrated dependent manner (Obersties and Giller 1996). Extracts of the leaf have been recommended for arthritic pain and dose is usually 750 mg/bid.
In interviewing 18 self-selected patients with joint pain who used nettle sting showed all but one were sure that the nettles had been very helpful, and several considered themselves cured. There were no side effects, except a transient urticarial rash. Nettle sting is useful, safe and a cheap therapy that may be beneficial for joint pain (Randall et al 1999).
Willow Bark Extract. Willow or Salix bark extracts contain salicin, and other derivatives including salicylic acid. The extract is an NSAID (herb) except that fewer side-effects have been reported as compared to aspirin or other pharmaceutical NSAIDs. In a study of low back pain patients received oral willow bark extract at 120 mg/day (low-dose) or 240 mg/day of willow bark extract (high-dose) in a 4-week blinded trial. The percentage of pain-free patients in the last week of treatment was 39% in the group receiving the high-dose extract, 21% in the group receiving the low-dose extract and 6% in the placebo group. The response rate in the high-dose group was evident after one week of treatment. Significantly more patients in the placebo group required pain medication during each week of the study (Chrubasik et al 2000).
Folic Acid. Folic acid supplementation may lower toxicity in patients treated with methotrexate for RA. Folic acid however does not seem to improve treatment efficacy. Low blood folate levels and increased mean corpuscular volumes are associated with substantial methotrexate toxicity. Daily dietary intakes of more than 900 nmol or 400 ug of folic acid were associated with less methotrexate toxicity (Morgan Sarah et al 1994).
Selenium. Plasma selenium levels were found to be significantly lower in RA patients than healthy controls. Selenium appears to be an important factor in RA. The low selenium values in RA are probably not just a nonspecific consequence of inflammation, but a sign of depletion of stores or redistribution of total body selenium (Kose, Kader, et al 1996).
Exercise. A study of dance-based exercise program in individuals with RA showed dance-based exercise to be a safe and efficient activity to improve physical fitness and psychological well being in individuals with RA. Positive changes in depression, anxiety, fatigue and tension were observed after the 12-week exercise program. These findings provide evidence in favor of aerobic exercise in individuals with rheumatoid arthritis. It is of primary interest to note that a weight-bearing activity with limited ground impact does not provoke short term adverse effects on the joints (Noreau, Luc, et al 1995).
Photochemotherapy. Eight patients with psoriasis and seronegative arthritis received photopheresis for 12 weeks, followed by photopheresis plus psoralen-ultraviolet A irradiation (PUVA) for another 12 weeks. Four patients had marked improvement of joint symptoms that lasted more than 12 months after the therapy. These responders had a higher CD4:CD8 ratio than poor responders prior to therapy Vahlquist, Carin, et al 1996). Photochemotherapy may be used for RA as well (Haberman, Herbert 1995).
Counseling. Counseling and special stress management skills in RA patients may result in less helplessness, less pain and greater mobility continuing several months after completion compared to those who had no counseling. There is evidence that the coping capacity of persons with RA are severely challenged by major life stresses associated with the disease (Tamkins 1996).
General recommendations for RA: