Research - Arthritis
The Effects of Yoga on Pain, Mobility, and Quality of Life in Patients with Knee Osteoarthritis: A Systematic Review
Laidi Kan,1,2 Jiaqi Zhang,3 Yonghong Yang,1,2,4 and Pu Wang1,2,4
Objective. To systematically assess the effects of yoga on pain, mobility, and quality of life in patients with knee osteoarthritis.
Methods. Pubmed, Medline, EMBASE, the Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database (PEDro), and other sources were searched systematically in this study. Two reviewers identified eligible studies and extracted data independently. Downs and Black’s Quality Index were used to evaluate the methodological quality of the included studies.
Results. A total of 9 articles (6 studies) involving 372 patients with knee osteoarthritis met the inclusion criteria. The most common yoga protocol is 40~90 minutes/session, lasting for at least 8 weeks. The effect of yoga on pain relief and function improvement could be seen after two-week intervention.
Conclusion. This systematic review showed that yoga might have positive effects in relieving pain and mobility on patients with KOA, but the effects on quality of life (QOL) are unclear. Besides, more outcome measure related to mental health of yoga effects on people with KOA should be conducted.
Source : Evidence Based Complementary and Alternative Medicine
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Tripterygium wilfordii Hook F versus conventional synthetic disease-modifying anti-rheumatic drugs as monotherapy for rheumatoid arthritis: a systematic review and network meta-analysis
- Hai-Long Wang
- Quan Jiang,
- Xing-Hua Feng,
- Hua-Dong Zhang,
- Lin Ge,
- Cheng-Gui Luo,
- Xun Gong and
- Bo Li
Background Tripterygium wilfordii Hook F (TwHF), a medicinal plant that has been widely used in Chinese traditional medicine, is proven effective for treating rheumatoid arthritis (RA), but its clinical efficacy and safety remain largely undefined in comparison with conventional synthetic disease modifying anti-rheumatic drugs (DMARDs).
Methods PubMed, Embase, Cochrane Library, CNKI, VIP, CBM, and WanFang Databases. Endpoints were ACR 20, 50, and 70, and the number of withdrawals due to adverse events. Initially, traditional pairwise meta-analysis was performed by using a random-effects model. Then, we performed network meta-analysis to compare different therapies by using frequentist approach.
Results A total of 22 trials (5255 participants) were identified. By direct comparison, TwHF was superior to sulphasalazine according to ACR 20, 50 and 70. TwHF was superior to placebo according to ACR 20 and 50. By indirect comparisons, TwHF was superior to methotrexate, leflunomide, sulphasalazine, tacrolimus, minocycline and placebo according to ACR 20. Ranking by the Surface under the Cumulative Ranking curve (SUCRA) values showed that TwHF had the greatest probability for being the best treatment option according to ACR 20 (92.0 %) and ACR 50 (81.3 %), and the highest probability to be in the second (57.8 %) ranking position after leflunomide (69.6 %) according to ACR 70. By both direct and indirect comparisons, TwHF caused no more significant withdrawals than the placebo. The SUCRA values showed that TwHF had the highest probability to rank sixth (26.7 %) after the placebo (45.6 %) in causing withdrawals.
Conclusions Our data suggest that TwHF is effective and safe in the treatment of RA and has better clinical efficacy in terms of ACR 20 and 50 than existing conventional synthetic DMARDs. In the absence of head-to-head treatment comparison, the confidence in these estimates is low. Future comparative efficacy studies are warranted.
Source : BMC Complementary and Alternative Medicine
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Effect of Xinfeng capsule in the treatment of active rheumatoid arthritis: a randomized controlled trial
Objective To explore the use of Xinfeng capsule (XFC) in the treatment of active rheumatoid arthritis (RA) and its effect on immunoglobulin titer, B cell-activating factor (BAFF) and its receptor (BAFF-R).
Methods A multi-center randomized, double-blind, parallel-controlled study was conducted. 45 RA patients were assigned to two groups: one was treated with XFC plus the placebo for leflunomide (LEF) and the second group was treated with LEF plus XFC placebo, for 12 weeks. The clinical and laboratory parameters were collected at baseline and at 12 weeks.
Results After 12 weeks of treatment, patients in the two groups all showed an therapeutic effect when ACR20, ACR50 and ACR70 were compared, but the differences between two groups were not significant (P < 0.05). The serum levels of IgG1, BAFF and BAFF-R in the XFC group were lower than those in the LEF group (P < 0.05). The level IgG subtypes correlated with clinical parameters; IgG2 levels positively correlated with C-reactive protein (CRP) (P < 0.01); IgG3 levels positively correlated with white blood cell count and CRP (P < 0.01); IgG4 levels positively correlated with Complement 4 (C4) (P < 0.01); the level of BAFF negatively correlated with Lymphocyte (LYMPH#) (P < 0.01); however, BAFF-R positively correlated with Platelet (PLT) and a1-acid glycoprotein (AGP) (P < 0.01).
Conclusion XFC can regulate the level of BAFF/BAFF-R in active rheumatoid arthritis and improve the levels of immunoglobulins in RA patients.
Source : Journal of Traditional Chinese Medicine
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Smoking Worsens Inflamed Joints
Important in the transition from genetic risk to symptomatic disease
Age and cigarette smoking increase the risk of inflammatory joint signs among first-degree relatives of patients with rheumatoid arthritis (RA), U.S. researchers have found.
Smoking at younger ages increased this risk more than four-fold, they reported online inArthritis & Rheumatology.
"Our findings add to the literature that smoking is an important, and potentially modifiable, risk factor during pre-clinical transitional phases of RA pathogenesis," wroteJeffrey A. Sparks, MD, Brigham and Women's Hospital, Boston, and co-investigators. "In our study, those who smoked more than 10 pack-years as well as current smokers had significantly increased odds for tender and swollen joints both at baseline and after 2 years of follow-up."
The Studies of the Etiology of Rheumatoid Arthritis cohort was used to evaluate RA risk factors and inflammatory joint signs in a prospective cohort of 966 non-Hispanic white first-degree relatives without RA. Their mean age was 47.2 years, 70.8% were female, and 43.7% had ever smoked. Most (54.9%) had at least one HLA shared epitope allele.
Inflammatory joint signs were tender or swollen joints on a 68-count joint examination. Only inflammatory joint signs at small joints at RA-specific sites were considered, according to the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria.
At baseline, 23% of the first-degree relatives had at least one swollen/tender joint present at RA-specific sites by physical examination. Eighty (8.3%) had one or more swollen joints and 195 (20.2%) had one or more tender joints at baseline.
Increasing age was significantly associated with any swollen joint (OR 1.04, 95% CI 1.02-1.05), any tender joint (OR 1.03, 95% CI 1.02-1.04), and any swollen/tender joint (OR 1.03, 95% CI 1.02-1.04).
Compared with never smoking, more than 10 pack-years of smoking was associated with any swollen joint (OR 1.89, 95% CI 1.05-3.41), any tender joint (OR 1.87, 95% CI 1.23-2.83), and any swollen/tender joint (OR 1.89, 95% CI 1.26-2.82).
Compared with never smoking, current smoking was associated with swollen joints (OR 2.51, 95% CI 1.28-4.94) and swollen metacarpophalangeal/wrist (OR 1.96, 95% CI 1.14-7.72).
The risk of inflammatory joint signs increased with heavier smoking in all age groups, but this risk was especially high among those with more than 10 smoking pack-years who were younger than 50 years. Among those younger than 50, those who smoked more than 10 pack-years had an odds ratio of 4.39 (95% CI 2.23-8.66) for swollen/tender joints compared with never smokers.
Among those 50 years and older, there was no significant association between smoking pack-years and inflammatory joint signs.
"Our findings provide evidence that smoking is important in the transition from genetic risk to symptomatic and objective inflammatory joint findings prior to RA onset and that this risk is highest for heavy smokers at younger ages," Sparks and colleagues wrote.
"These findings emphasize the public health importance of smoking cessation, particularly among younger family members of patients with RA."
There was no interaction for HLA shared epitope and smoking (P=0.34) or RA-related autoantibodies and smoking (P=0.90) for inflammatory joint signs.
Neither genetic risk score nor RA-related autoantibodies were associated with inflammatory joint signs at baseline.
Age (OR 1.05, 95% CI 1.02-1.08) and smoking >10 pack-years (OR 2.66, 95% CI 1.01-7.03) were associated with incident inflammatory joint signs at 2 years. Environmental RA risk factors, genetic risk score, and RA-related autoantibodies were not associated with inflammatory joint signs after 2 years of prospective follow-up.
The researchers speculated that smoking plays a dual role in the pathogenesis of RA by inducing autoantibody production while also propagating joint inflammation. "Since smoking was associated with inflammatory joint signs even in the absence of autoantibodies, inflammatory joint signs may develop before detectable autoantibodies," they wrote.
"Since few participants in our study were seropositive, our findings provide evidence that smoking promotes inflammatory arthritis independent of the presence of serologic RA-related autoantibodies and independent of the shared epitope."
Among study limitations, the authors listed potential misclassification of inflammatory arthritis by physical examination. Also, the study may have been underpowered to find true associations between other established RA risk factors and inflammatory joint signs, given the low number of outcomes in the study
Source : MedPage Today
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Efficacy and safety of Xinfeng capsule in patients with rheumatoid arthritis: a multi-center parallel-group double-blind randomized controlled trial
Liu Jiana, , , Wang Yuana, Huang Chuanbinga, Xu Jianhuab, Li Zhijunc, Xu Liangd, He Liyune, Sun Yuea, Wang Yalia, Xu Shengqianb, Zhao Pingc, Mao Tongjund, Tan Bina, Zhu Fubinga, Zhang Pinghenga,Fang Lia
To evaluate the efficacy and safety of Xinfeng capsule in patients suffering rheumatoid arthritis (RA).
A multi-center parallel-group designed, double-blind, randomized, controlled trial was conducted. Totally 304 RA patients were assigned to two groups: one group was administered Xinfeng capsule (XFC) plus the placebo of leflunomide and the other given leflunomide (LEF) plus the placebo of XFC for twelve weeks. The clinical and laboratory parameters were compared at baseline and fourth, eighth, and twelfth weeks.
After twelve-week treatment, patients in two groups all showed some trend of effectiveness when compared in terms of American Rheumatism Association (ACR) recommended 20%, 50%, 70% improvement criteria, but it was insignificant. The validity in ameliorate modified disease activity score (DAS28) and laboratory indexes as erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF) were also found no difference. The score of health assessment questionnaire (HAQ), self-rating anxiety scale (SAS), self-rating depression scale (SDS) and quality of life questionnaire with rheumatoid arthritis (RAQOL) both lower than the first week and the changes showed no difference. However, the score of SDS dropped more in XFC group than in the other. A total of 147 adverse reaction cases were reported, which shows no difference between the two groups. The most common adverse reactions were hepatic impairment, anemia, leukocytopenia, epigastric discomfort and phalacrosis.
XFC demonstrated better improvement in the scores of SDS and compared with those of LEF group.
Source Journal of Traditional Chinese Medicine
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Chamomile Oil Improves Pain, Stiffness, and Function in Patients with Knee Osteoarthritis
Shoara R, Hashempur MH, Ashraf A, Salehi A, Dehshahri S, Habibagahi Z. Efficacy and safety of topicalMatricaria chamomilla L. (chamomile) oil for knee osteoarthritis: a randomized controlled clinical trial.Complement Ther Clin Pract. 2015;21(3):181-187.
Knee osteoarthritis (OA) causes pain, physical dependency, and impaired mobility in the elderly. OA is often treated with analgesics; however, the adverse side effects associated with analgesics, as well as patients' comorbidities such as ischemic heart disease and gastric upset, can limit their use. In traditional Persian medicine, chamomile (Matricaria recutita syn. M. chamomilla, Asteraceae) oil is used for its therapeutic effects and is often prescribed for joint pain. These authors conducted a 3-arm, parallel, blinded, randomized, placebo-controlled trial to assess the efficacy and safety of topical chamomile oil in the treatment of knee OA.
Dried chamomile flowers (600 g), purchased at a local market in Shiraz in southern Iran, were boiled in 3.6 L water, then combined with sesame (Sesamum indicum, Pedaliaceae) oil, and further concentrated by vaporization. Pharmaceutical grade paraffin was used as the placebo. Diclofenac gel 1% (Behvazan Pharmaceutical Co.; Tehran, Iran), a nonsteroidal anti-inflammatory drug, served as the positive control medication for the third arm of the study.
Male and female patients at Shahid Motahari Outpatient Clinic at Shiraz (Iran) University of Medical Sciences, aged between 38 and 65 years, were eligible for the study if they had knee OA meeting the criteria of the American College of Rheumatology and grade 1 to 3 OA according to the Kellgren-Lawrence Grading Scale.
From January 2015 to March 2015, 130 patients were assessed for eligibility. Of those, 99 were randomly assigned to 1 of the 3 treatment arms. Twenty-eight patients in each group completed the study. In the chamomile group, 4 dropped out for personal reasons, and 1 was lost to follow-up. Five patients in the placebo group and 5 in the diclofenac control group dropped out for personal reasons.
All patients were instructed to apply the prescribed medication 3 times daily for 3 weeks and advised not to massage the treatment area.
Acetaminophen (500 mg tablets) was allowed as a rescue drug during the trial, and its use was one of the study's outcome measures.
Another outcome measure was the score on the self-administered Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, which evaluated the patients on the following 3 domains:
- Pain, ranging from 0 (no pain) to 4 (extreme pain
- Physical function, ranging from 0 (no difficulty) to 4 (most severe difficulty
- Stiffness, ranging from 0 (no stiffness) to 4 (the worse stiffness)
The authors reported the number of acetaminophen tablets used by patients was significantly lower in the chamomile group (21.00 ± 10.35) compared with the diclofenac (28.14 ± 4.90) and placebo (27.46 ± 7.10) groups (P=0.001). The authors suggested the polyphenolic compounds of chamomile can have anti-inflammatory effects and may explain the decreased demand for analgesics in the chamomile group.
Results of the responses of the WOMAC questionnaire revealed significant improvements in pain, physical function, and stiffness in all groups when compared with baseline scores (P<0.001 for all); no significant differences were observed among the 3 groups. The chamomile oil improved WOMAC scores similar to the diclofenac, it is lower in cost than the diclofenac, and fewer analgesics were required with its use.
Chamomile oil was well tolerated by patients. No adverse side effects were reported, and no abnormal physical findings were noted.
The authors point out that because they used sesame oil as the vehicle for the active constituents of the chamomile flower, they cannot attribute the results solely to the chamomile. Sesame oil also has demonstrated antioxidant, anti-inflammatory, and anesthetic properties. Other limitations of the study include the short duration, the relatively small sample size, and the small percentage (15.5%) of male patients in the study, which would limit the generalizability of the results for male patients with knee OA.
The authors conclude that the topical use of a traditional formulation of chamomile oil can decrease the need for analgesics in patients with knee OA and produces some beneficial effects on pain, physical function, and stiffness.
Source : American Botanical Council - Herbclip
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Gait analysis of patients with knee osteoarthritis before and after Chinese massage treatment
The objective of this study was to evaluate the effectiveness of Chinese massage therapy in patients with knee osteoarthritis (OA) by measuring lower-limb gait parameters. We recruited 20 women with knee OA, who then underwent Chinese massage therapy three times per week for 2 weeks. The patients underwent gait evaluation using a six-camera infrared motion analysis system. They completed Western Ontario and McMaster Universities Osteoarthritis Index questionnaires before and after treatment. We calculated the forward speed, step width, step length, total support time percentage, initial double support time percentage, and single support time percentage. We also measured the angles at the knee, hip, and ankle during the stance phase of walking. The results showed statistically significant mean differences in knee pain relief, alleviation of stiffness, and physical function enhancement after therapy (P < 0.05). The patients gained significantly faster gait speed, greater step width, and increased total support time percentage after the Chinese massage therapy (P < 0.05). There were no significant differences in the range of motion or initial contact angles of the knee, hip, or ankle during the stance phase of walking. We concluded that Chinese massage is a beneficial complementary treatment and an alternative therapy choice for patients with knee OA for short-term pain relief. Chinese massage may improve walking ability for these patients
Source : Journal of Traditional Chinese Medicine
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Effect of Chinese herbal compound Tengmei decotion on IL-17/NF-κB signal pathway in synovium tissue of rat arthritis models induced by type II collage
Purpose: To investigate the biological effect of IL-17/NF-κB immune inflammatory pathway on pathological damage in synovium tissue of Rheumatoid arthritis (RA) and study in regulation mechanism of Chinese herbal compound Tengmei decotion for IL-17/NF-κB signal pathway.
Methods: To establish collagen II-induced rats arthritis(CIA)models. The successful models of SD rats were randomly divided into model group, positive group, and high-, medium- groups of Chinese medicine, 6 rats in each group. The normal control and model groups were given distilled water (10ml kg-1 d) by gavage. The positive drug group was given leflunomide (1.87g kg-1 d) by gavage. The high and medium dose Chinese medicine groups were given crude medicine of 31.8 g kg-1 d and 15.9 g kg-1 d by gavage. After twelve weeks of treatment intervention, all SD rats were executed, the blood and synovium tissue samples were kept for detecting IL-17, NF-KB P65 mRNA transcription and protein expression by RT-PCR, WESTEN BLOT and ELISA Analysis, and detecting inflammatory infiltration in synovium tissue by Histopathological analysis.
Results: (1)Compared to the normal control group, levels of mRNA transcription and protein expression of IL-17 and NF-κB P65 were significantly up-regulated (P < 0.01) in the model group. Compared to the model group, levels of mRNA transcription and protein expression of IL-17 and NF-κB P65 were significantly down-regulated in the positive and Chinese medicine groups (P < 0.01).(2) Histopathological analysis displayed that mild hyperplasia of epithelial cells covering the articular cartilage synovium, joint cavity narrowing, and mild inflammatory lymphocytes infiltration in model group, with joint lesions improved in treatment groups.
Conclusion: The molecular mechanisms of Chinese herbal Tengmei decotion in inhibiting immune inflammatory pathological damage in synovium of CIA rats models related to its effects on IL-17/NF-κB pathway.
Source : Integrative Medicine Research
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Oral administration of apple condensed tannins delays rheumatoid arthritis development in mice via downregulation of T helper 17 (Th17) cell responses
- Kosuke Nakamura1,†,*,
- Hideki Matsuoka1,†,
- Syohei Nakashima2,
- Tomomasa Kanda2,
- Tomoko Nishimaki-Mogami1 and
- Hiroshi Akiyama1
Apples are known to contain high concentrations of phenolic compounds such as condensed tannins. Consumption of condensed tannins has been reported to reduce the risk of many types of chronic diseases including allergies. However, their therapeutic effectiveness and potential in treating autoimmune disease remain controversial. Here, the effect of oral administration of apple condensed tannins (ACT) prepared from apples (Malus pumila cv. Fuji) on bovine type II collagen (CII)-induced arthritis in DBA1/J mice, a well-established murine model of human rheumatoid arthritis (RA), was evaluated. As compared to the control (without ACT administration) group, RA development was delayed and a significant reduction in the RA clinical score was observed in the ACT-administered group. Using cultured splenocytes isolated from CII-immunized mice, ACT-administration was shown to decrease the CII-induced increases in IL-17 expression and production in vitro. We propose that downregulation of T helper (Th) 17 cells is responsible for the ACT-induced RA suppression.
Source : Molecular Nutrition and Food Research
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The Clinical Efficacy and Safety of the Sahastara Remedy versus Diclofenac in the Treatment of Osteoarthritis of the Knee: A Double-Blind, Randomized, and Controlled Trial
Piya Pinsornsak, 1 Puritat Kanokkangsadal, 2 and Arunporn Itharat 2 , 3 , *
Introduction. The Sahastara (SHT) remedy is a Thai traditional medicine that has been acknowledged in the Thai National List of Essential Medicine and has been used as an alternative medicine to treat knee osteoarthritis. Although SHT remedies have been used in Thai traditional medical practices for a long period of time, there are few reports on their clinical trials.
Aim of the Study. To investigate the clinical efficacy and safety of the SHT remedy in treating OA of the knee when compared to diclofenac.
Methods. A phase 2, double-blind, randomized, and controlled trial study with a purpose to determine the clinical efficacy and safety of SHT in comparison with diclofenac for the treatment of knee osteoarthritis. Sixty-six patients, ages between 45 and 80 years of age, were randomly allocated into 2 groups. The SHT group received 1,000 mg of SHT powdered capsules 3 times per day, orally before meals, while another group received 25 mg of diclofenac sodium capsules 3 times a day, orally after meals for 28 days. All patients were followed up at 14 and 28 days for the evaluation of the efficacy and safety by using clinical examinations, blood tests, a visual analogue scale (VAS) for pain, and the 100-meter walktime test. Improvement on the quality of life was also assessed by the WOMAC index.
Results. There were 31 and 30 patients in SHT and diclofenac groups, respectively, who had completed the study. Both medications have shown to significantly reduce the VAS for pain, and significantly improve the 100-meter walktime test and the WOMAC index score. However, there were no differences in the efficacy between the two groups. The blood chemistry showed no toxicity on renal and/or liver functions after taking SHT for 28 days but the patients who took diclofenac showed significant increases in their AST, ALT, and ALP. Systolic and diastolic blood pressure slightly increased in the diclofenac group but the SHT group did not effect on blood pressure.
Conclusions. The SHT remedy is similar to diclofenac in all evaluating symptoms of OA knee. However, the SHT remedy has shown to be a good alternative treatment for OA knee with less systemic side effects when it was compared with diclofenac.
Source : Evidence Based Complementary and Alternative Medicine
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Chondroitin for osteoarthritis
- Jasvinder A Singh1,*,
- Shahrzad Noorbaloochi2,
- Roderick MacDonald3,
- Lara J Maxwell4
Osteoarthritis, a common joint disorder, is one of the leading causes of disability. Chondroitin has emerged as a new treatment. Previous meta-analyses have shown contradictory results on the efficacy of chondroitin. This, in addition to the publication of more trials, necessitates a systematic review.
To evaluate the benefit and harm of oral chondroitin for treating osteoarthritis compared with placebo or a comparator oral medication including, but not limited to, nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, opioids, and glucosamine or other "herbal" medications.
We searched seven databases up to November 2013, including the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, CINAHL, EMBASE, Science Citation Index (Web of Science) and Current Controlled Trials. We searched the US Food and Drug Administration (FDA) and European Medicines Agency (EMEA) websites for adverse effects. Trial registers were not searched.
All randomized or quasi-randomized clinical trials lasting longer than two weeks, studying adults with osteoarthritis in any joint, and comparing chondroitin with placebo, an active control such as NSAIDs, or other "herbal" supplements such as glucosamine.
Data collection and analysis
Two review authors independently performed all title assessments, data extractions, and risk of bias assessments.
Forty-three randomized controlled trials including 4,962 participants treated with chondroitin and 4,148 participants given placebo or another control were included. The majority of trials were in knee OA, with few in hip and hand OA. Trial duration varied from 1 month to 3 years. Participants treated with chondroitin achieved statistically significantly and clinically meaningful better pain scores (0-100) in studies less than 6 months than those given placebo with an absolute risk difference of 10% lower (95% confidence interval (CI), 15% to 6% lower; number needed to treat (NNT) = 5 (95% CI, 3 to 8; n = 8 trials) (level of evidence, low; risk of bias, high); but there was high heterogeneity between the trials (T2 = 0.07; I2 = 70%, which was not easily explained by differences in risk of bias or study sample size). In studies longer than 6 months, the absolute risk difference for pain was 9% lower (95% CI 18% lower to 0%); n = 6 trials; T2 = 0.18; I2 = 83% ), again with low level of evidence.
For the Western Ontario and McMaster Universities Osteoarthritis Index Minimal Clinically Important Improvement (WOMAC MCII Pain subscale) outcome, a reduction in knee pain by 20% was achieved by 53/100 in the chondroitin group versus 47/100 in the placebo group, an absolute risk difference of 6% (95% CI 1% to 11%), (RR 1.12, 95% CI 1.01 to 1.24; T2 = 0.00; I2 = 0%) (n = 2 trials, 1253 participants; level of evidence, high; risk of bias, low).
Differences in Lequesne's index (composite of pain,function and disability) statistically significantly favoured chondroitin as compared with placebo in studies under six months, with an absolute risk difference of 8% lower (95% CI 12% to 5% lower; T2= 0.78; n = 7 trials) (level of evidence, moderate; risk of bias, unclear), also clinically meaningful. Loss of minimum joint space width in the chondroitin group was statistically significantly less than in the placebo group, with a relative risk difference of 4.7% less (95% CI 1.6% to 7.8% less; n = 2 trials) (level of evidence, high; risk of bias, low). Chondroitin was associated with statistically significantly lower odds of serious adverse events compared with placebo with Peto odds ratio of 0.40 (95% CI 0.19 to 0.82; n = 6 trials) (level of evidence, moderate). Chondroitin did not result in statistically significant numbers of adverse events or withdrawals due to adverse events compared with placebo or another drug. Adverse events were reported in a limited fashion, with some studies providing data and others not.
Comparisons of chondroitin taken alone or in combination with glucosamine or another supplement showed a statistically significant reduction in pain (0-100) when compared with placebo or an active control, with an absolute risk difference of 10% lower (95% CI 14% to 5% lower); NNT = 4 (95% CI 3 to 6); T2 = 0.33; I2 = 91%; n = 17 trials) (level of evidence, low). For physical function, chondroitin in combination with glucosamine or another supplement showed no statistically significant difference from placebo or an active control, with an absolute risk difference of 1% lower (95% CI 6% lower to 3% higher with T2 = 0.04; n = 5 trials) (level of evidence, moderate). Differences in Lequesne's index statistically significantly favoured chondroitin as compared with placebo, with an absolute risk difference of 8% lower (95% CI, 12% to 4% lower; T2 = 0.12; n = 10 trials) (level of evidence, moderate). Chondroitin in combination with glucosamine did not result in statistically significant differences in the numbers of adverse events, withdrawals due to adverse events, or in the numbers of serious adverse events compared with placebo or with an active control.
The beneficial effects of chondroitin in pain and Lequesne's index persisted when evidence was limited to studies with adequate blinding or studies that used appropriate intention to treat (ITT) analyses. These beneficial effects were uncertain when we limited data to studies with appropriate allocation concealment or a large study sample (> 200) or to studies without pharmaceutical funding.
A review of randomized trials of mostly low quality reveals that chondroitin (alone or in combination with glucosamine) was better than placebo in improving pain in participants with osteoarthritis in short-term studies. The benefit was small to moderate with an 8 point greater improvement in pain (range 0 to 100) and a 2 point greater improvement in Lequesne's index (range 0 to 24), both seeming clinically meaningful. These differences persisted in some sensitivity analyses and not others. Chondroitin had a lower risk of serious adverse events compared with control. More high-quality studies are needed to explore the role of chondroitin in the treatment of osteoarthritis. The combination of some efficacy and low risk associated with chondroitin may explain its popularity among patients as an over-the-counter supplement.
Plain Language Summary
We conducted a review of the effects of chondroitin sulfate for people with osteoarthritis. We found 43 studies with 9,110 people after searching for studies up to November 2013. Majority were studies of knee osteoarthritis (few hand, one hip) ranging from 1 month to 3 years. Several studies were funded by makers of chondroitin.
This review shows that in people with osteoarthritis:
- Chondroitin may improve pain slightly in the short-term (less than 6 months);
- Chondroitin improves knee pain by 20% in slightly more people;
- Chondroitin probably improves quality of life slightly as measured by Lequesne's index (combined measure of pain, function, and disability);
- Chondroitin has little or no difference in adverse and serious adverse events versus other agents; and
- Chondroitin slightly slows down the narrowing of joint space on X-rays of the affected joint.
We identified a lot of studies in which unsound methods were used to assess the effects of chondroitin. For some outcomes, there was not enough data. In some studies, whose methodological quality was better, chondroitin showed no improvement in pain and in physical function. Other analyses based on different methodological quality criteria reported improvement in pain and physical functionality when chondroitin was given.
Source : The Cochrane Library
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Curcuminoid Supplementation Improves Knee Osteoarthritis Symptoms
Panahi Y, Rahimnia AR, Sharafi M, Alishiri G, Saburi A, Sahebkar A. Curcuminoid treatment for knee osteoarthritis: a randomized double-blind placebo-controlled trial. Phytother Res. November 2014;28(11):1625-1631.
The most common joint disease in adults, osteoarthritis (OA) is characterized by chronic joint pain, inflammation, stiffness, and limited mobility. Standard treatment is the prescription of analgesics and non-steroidal anti-inflammatory drugs (NSAIDs); however, NSAIDs are only partially effective and may cause adverse gastrointestinal, renal, and cardiovascular effects. Experimental studies have found that the curcuminoid constituents (2-5%) of turmeric (Curcuma longa, Zingiberaceae) have significant analgesic, anti-inflammatory, and antioxidant properties. Preliminary clinical evidence suggests curcuminoids may be an effective alternative or adjunct treatment for OA. In this randomized, double-blind, placebo-controlled pilot study, the effect of curcuminoid supplementation on clinical measures of knee OA symptoms was measured.
Patients under the age of 80 with mild-to-moderate knee OA (n=60) were recruited from Baqiyatallah University Clinic in Tehran, Iran. Diagnoses of knee OA were based on the clinical and radiological criteria of the American College of Rheumatology and a minimum score of 40 mm on a 100 mm visual analog scale (VAS) of joint pain. The exclusion criteria were as follows: known allergy to curcuminoids or other herbs; candidates for knee replacement or any other surgery; OA secondary to trauma; rheumatoid arthritis, inflammatory disorders, or hemophilia; malabsorption disorders; active, generalized inflammatory conditions; heart, renal, or liver failure; history of psychological disorders; using ˃10 mg/day corticosteroids in the prior 3 months; and intra-articular injections in the last 3 months.
The eligible consenting patients (n=53) were consecutively randomly assigned to receive either 500 mg 3x/day (1500 mg/day) of curcuminoids (n=27; C3 Complex®; Sami Labs Ltd; Bangalore, India) or a size- and shape-matched placebo (n=26; inert starch) for 6 weeks. Each C3 Complex capsule contained 500 mg curcuminoids and 5 mg BioPerine® (Sami Labs Ltd). BioPerine is a standardized extract of black pepper (Piper nigrum, Piperaceae) and/or long pepper (Piper longum) containing at least 95% piperine, which has been shown to increase the absorption of curcuminoids. All patients were allowed to use an escape medication (naproxen) when they had intolerable pain.
The change in OA symptoms was measured with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), OA pain severity rating on VAS, and the 5-item Lequesne's Pain Functional Index (LPFI). Adverse effects were recorded using a pre-designed checklist.
Forty patients completed the study with 19 in the treatment group and 21 in the placebo group. Eight patients in the treatment group and 5 patients in the placebo group were lost to follow-up. No reasons for the losses in either group were given. All patients were taking NSAIDs at baseline.
At the end of the study, there were significant reductions in the global WOMAC score and the pain, physical function, and stiffness subcategory scores in the treatment group (P < 0.001, P < 0.001, P < 0.001, and P = 0.043, respectively) compared to baseline. The scores for the WOMAC pain and stiffness subcategories were also significantly reduced in the placebo group (P = 0.025 and P = 0.009, respectively) compared to baseline. However, the global WOMAC score and scores for the subcategories of pain and physical function were all significantly lower in the treatment group compared to the placebo group at the end of the study (P = 0.001, P < 0.002, and P < 0.001, respectively). There was no significant difference between the treatment and placebo groups in the WOMAC stiffness subcategory.
Treatment with curcuminoids (but not placebo) significantly improved both the VAS and LPFI scores (P < 0.001 for both) compared to baseline. Compared to the placebo group, the magnitude of reduction in VAS and LPFI scores was significantly greater in the treatment group (P = 0.013 and P < 0.001, respectively). There was also a significant reduction (P < 0.001) in the use of NSAIDs in the treatment group (84%) compared to the placebo group (19%). No serious adverse events (AEs) were reported, and none of the dropouts were due to AEs. The most common AE was gastrointestinal distress with 7 patients in the treatment group and 4 in the placebo group affected.
Six weeks of curcuminoid supplementation resulted in marked improvement in symptoms of knee OA compared to the placebo. In addition, there was a significant reduction in the use of NSAIDs in the group taking curcuminoid supplements. The authors suggest that a plausible mechanism is the potent anti-inflammatory and antioxidant properties of curcuminoids. Curcuminoids have been shown to reduce the release of pro-inflammatory cytokines in cultured chondrocytes, increase chondrocyte survival, inhibit the production of reactive oxygen species which impair joint components, and scavenge free radicals which disrupt the cartilage matrix and promote the production of pain mediators.
The authors note several limitations of the study, including the small sample size and short duration, as well as the facts that the optimum dose and dose-response relationship were not determined and only patients with mild-to-moderate OA were evaluated. Based upon the positive safety and efficacy findings in this study, the authors conclude that larger scale (Phase III) trials should be conducted to confirm the results and investigate whether the effect is independent of analgesic mechanisms.
–Cheryl McCutchan, PhD
Source : American Botanical Council - Herbclip
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Spiritual Healing in the Treatment of Rheumatoid Arthritis: An Exploratory Single Centre, Parallel-Group, Double-Blind, Three-Arm, Randomised, Sham-Controlled Trial
Henning Bliddal,1 Robin Christensen,1,2 Lars Højgaard,3 Else Marie Bartels,1 Karen Ellegaard,1 Robert Zachariae,4 and Bente Danneskiold-Samsøe1
1The Parker Institute, Department of Rheumatology, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Nordre Fasanvej 57, 2000 Copenhagen, Denmark
2Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark
3Danish Healing Research Center, Stationsvej 16, 3210 Vejby, Denmark
4Unit for Psychooncology and Health Psychology, Department of Oncology, Aarhus University Hospital and Department of Psychology and Behavioral Science, Bartholins Allé 9, 8000 Aarhus C, Denmark
Our objective was to investigate the efficacy of “energy/spiritual healing” in rheumatoid arthritis (RA). Eligible patients were women with RA on stable medication. The design was a randomised, blinded, sham-controlled trial; the third group included an external unblinded control of the natural course of RA. Participants in both groups received 8 sessions with “perceived healing” over 21 weeks with 8 weeks of follow-up. Active healing (AH) treatment comprised healing with no physical contact, and sham healing (SH) included exactly the same healing with a sham healer. During intervention, participants wore hearing protectors and were blindfolded. No healing (NH) only had their outcomes assessed. Coprimary outcomes were disease activity score (DAS) for 28 joints and Doppler ultrasound. All 96 patients randomised were handled as the intention-to-treat population, using a baseline-carried forward approach to replace the missing data. Eighty-two (85%) participants completed the 29-week trial. At end point (week 29), mean difference in DAS28 between AH versus SH was statistically but not clinically significant in favour of AH (0.62 DAS28 points; 95% CI: 0.13 to 1.11; P=0.014), while no differences between groups occurred in Doppler ultrasound. There are no clear physiological or psychological explanations for the findings in this tightly controlled study. The trial data indicates a need for independent replication.
Taken together the results showing that “active healing” differed statistically, not clinically, from “sham healing,” but not from “no healing,” suggest two alternative interpretations. The most conservative explanation would be that the study stumbled upon a group of patients receiving active healing, which by chance experienced a decrease in arthritis activity in comparison with the sham healing group. Chance differences are not uncommon, and the validity of the findings can only be determined by replication of the study. An alternative interpretation is that “energy healing” is in fact able to influence biological processes relevant to rheumatoid arthritis through mechanisms not yet understood by conventional science. While supported by successful efforts to avoid bias through randomisation and blinding, which rules out the possibility that patients receiving healing improved due to effects of expectation or improved psychological coping skills, the latter interpretation is weakened by the results that no healing group showed equally improved outcomes and that the differences generally did not correspond to clinically significant improvement.
In the present well-controlled study, healing was associated with a statistically significant objective outcome in spite of the clinicians’ scepticism and the low expectations by the participants. The result is likely to be regarded as a chance of finding by traditional researchers and, in contrast, as an evidence of efficacy, when interpreted by alternatively inclined health providers. The growing interest in CAM from patients and the results from the current study suggest that further well-controlled trials would be relevant to provide evidence for or against the efficacy of spiritual healing.
Source : Journal Evidence Based Complementary and Alternative Medicine
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Weight Still Top Risk Factor for Knee Arthritis, Pain
Other factors include female gender, previous knee injury, age, and presence of hand OA.
Familiar risk factors for knee osteoarthritis (OA) in individuals 50 years and older -- high body mass index (BMI), previous knee injury, age, female sex, and the presence of hand OA -- were confirmed as the condition's top drivers in a new systematic review and meta-analysis with an updated evidence base.
One-fourth of cases of onset of knee pain could be attributable to being either overweight or obese, according to Victoria Silverwood and colleagues at the Arthritis Research UK Primary Care Centre at Keele University in Staffordshire, England.
The finding emphasizes "the continued importance of weight loss as a management option for OA," they wrote in Osteoarthritis and Cartilage. "Our calculated PAF [population attributable fraction] values demonstrate that 24.6% of cases of onset of knee pain could be attributed to being either overweight or obese."
Data from 46 published studies up to December 2012 were extracted for the systematic review to assess the association between potential risk factors and knee pain/knee OA in study cohorts with a mean age of 50 years and older. Thirty-four studies in which risk factors had consistent definitions across studies were included in the meta-analysis.
Meta-analysis was performed for five risk factors where a sufficient number of studies reported findings. These were: BMI, female gender, smoking, previous knee injury, and the presence of hand OA or Heberden's nodes.
There was consistent demonstration that being overweight was a risk factor for the onset of knee OA. Among 22 such studies included in the meta-analysis, the pooled odds ratio (OR) was 1.98 (95% CI 1.57-2.20).
Among 22 studies investigating obesity as a risk factor for onset of knee OA, all studies were generally consistent in reporting obesity as a risk factor despite a large amount of heterogeneity between study findings. The pooled OR of these studies was 2.66 (95% CI 2.15-3.28), a slightly larger effect on onset of knee OA than being overweight.
In 25 cohort studies reporting results, or from which results could be deduced, on the effect of being either overweight or obese on knee OA, the pooled OR was 2.10 (95% CI 1.82-2.42) with a large amount of heterogeneity between studies.
The pooled OR for previous knee injury as a risk factor for knee OA was 2.83 (95% CI 1.91-4.19) in 12 studies, which all showed an increased risk of knee OA with a prior injury, although heterogeneity between studies was considerable.
Evidence was consistent across 10 cohort studies that female gender was a risk factor, with a pooled OR of 1.68 (95% CI 1.37-2.07).
In six cohort studies, the pooled OR of hand OA as a risk factor for knee OA was 1.30 (95% CI 0.90-1.87) with moderate heterogeneity, indicating that it may potentially be a risk factor.
A pooled OR of 0.92 (95% CI 0.83-1.01) suggests that, overall, smoking is not associated with knee OA.
Among 19 studies assessing increasing age as a risk factor for knee OA, there was general agreement that increasing age is a significant risk factor, although establishing a pooled OR was not possible because of the range of different age categorizations.
Kneeling, lifting, and farm and construction work were each evaluated in fewer than five studies. "In summary, it would appear that individuals who are exposed to certain physically demanding activities in their daily working lives may be at an increased risk of developing knee pain and knee OA," the authors conclude.
Of 16 studies that assessed the effect of high levels of physical activity, 11 showed no statistically significant effect on development of knee OA, three showed a significant effect of intense activity, one found a significant effect of habitual activity, and another found a significant effect only in those who ran 20 or more miles per week.
Population attributable fractions were calculated for being overweight or obese, and indicated that 5.1% of new knee pain/knee OA could be attributed to a previous injury and 24.6% could be attributed to being overweight or obese.
"The results of this review can be used clinically to help healthcare professionals identify and manage patients at risk of developing or increasing knee OA," the authors wrote. "Some, such as weight, can be targeted clinically in order to reduce the number of patients who suffer from knee OA. Patients with other risk factors such as previous knee injury, age, and female gender can be managed to reduce progression of the condition."
The authors did not assess the quality of the studies in their review but noted that a previous review they conducted that did take into account the quality of studies made no difference in their findings. Not all potential risk factors (such as low muscle strength or malalignment) were considered. In addition, the definition of knee pain was self-reported and may not reflect radiographic knee OA.
Source : MedPage Today
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Effect of the herbal drug guilu erxian jiao on muscle strength, articular pain, and disability in elderly men with knee osteoarthritis.
Tsai CC1, Chou YY2, Chen YM3, Tang YJ4, Ho HC5, Chen DY6.
Background. Guilu Erxian Jiao (GEJ) is a widely used Chinese herbal remedy for knee osteoarthritis, but its clinical efficacy is unknown. Methods. We enrolled 42 elderly male patients with knee OA, including 21 patients who received the herbal drug GEJ as the case group and 21 patients who did not receive GEJ as the control group. The effects of 12 weeks of GEJ treatment on muscle strength of lower limbs were measured by a Biodex dynamometer, with disability evaluated on the Lequesne index and articular pain measured on the visual analog scale (VAS) between the two groups on the baseline and after treatment.
Results. There were significant increases in the levels of muscle strength of TQ/BW-ext-dominant and TQ/BW-flex-dominant between the two groups after treatment (P < 0.05). There were also significant increases in muscle strength of knee extensor muscles in the GEJ-treated group (n = 21) self-controlled before and after 12 weeks of treatment (all P < 0.01). There were significant decreases in articular pain (P < 0.01) and Lequesne index scores (P < 0.01) in the GEJ-treated group when compared to the non-GEJ-treated group.
Conclusions. Our results showed that GEJ is effective and is tolerated well in elderly men with knee OA.
Source : Journal Evidence Based Complementary and Alternative Medicine
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A Combination of Scutellaria Baicalensis and Acacia Catechu Extractsfor Short-Term Symptomatic Relief of Joint Discomfort Associated with Osteoarthritis of the Knee
Bahram H. Arjmandi,1,2Lauren T. Ormsbee,1,2Marcus L. Elam,1,2Sara C. Campbell,3Nader Rahnama,1,2,4Mark E. Payton,5Ken Brummel-Smith,6and Bruce P. Daggy,1,2
1Department of Nutrition, Food, and Exercise Sciences
,2Center for Advancing Exercise and Nutrition Research on Aging,and 6Department of Geriatrics, College of Medicine, the Florida State University, Tallahassee, Florida, USA.
3Department of Exercise Science and Sport Studies, Rutgers University, the State University of New Jersey,New Brunswick, New Jersey, USA
4Faculty of Sports Sciences, University of Isfahan, Isfahan, Iran.
5Department of Statistics, Oklahoma State University, Stillwater, Oklahoma, USA.
The extracts of Scutellaria baicalensis and Acacia catechu have been shown in previous studies to alleviate joint discomfort, reduce stiffness, and improve mobility by reducing the production of proinflammatory molecules over long periods of supplementation. The acute effects of intake of these extracts have not yet been investigated. Thus, we carried out a1 week clinical trial to examine the extent to which UP446—a natural proprietary blend of S. baicalensis and A. catechu (UP446)—decreases knee joint pain, mobility, and biomarkers of inflammation in comparison to naproxen. Seventy-nine men and women (40–90 years old) diagnosed as having mild to moderate osteoarthritis (OA) consumed either 500mg/day of the UP446 supplement or 440mg/day of naproxen for 1 week in a double-blind randomized control trial. Pain, knee range of motion(ROM), and overall physical activity were evaluated at the start and at the end of treatment. Fasting blood was collected to determine serum interleukins 1band 6, tumor necrosis factor-a, C-reactive protein, and hyaluronic acid. The UP446 group experienced a significant decrease in perceived pain (P=.009) time dependently. Stiffness was significantly reduced by both treatments (P=.002 UP446,P=.008 naproxen). Significant increases in mean ROM over time (P=.04) were found in the UP446group. These findings suggest that UP446 is effective in reducing the physical symptoms associated with knee OA.
Source : Journal of Medicinal Foods
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Decrease of a specific biomarker of collagen degradation in osteoarthritis, Coll2-1, by treatment with highly bioavailable curcumin during an exploratory clinical trial
Yves Henrotin12*, Myriam Gharbi3, Yvan Dierckxsens4, Fabian Priem5, Marc Marty6, Laurence Seidel7, Adelin Albert7, Elisabeth Heuse8, Valérie Bonnet8 and Caroline Castermans8
1 Bone and Cartilage Research Unit, Institute of Pathology, University of Liège, Level 5, CHU Sart-Tilman, 4000 Liège, Belgium
2 Department of Physical Therapy and Rehabilitation, Princess Paola Hospital, Vivalia, Marche-en-Famenne, Belgium
3 Artialis S.A, CIGA tower, level 3, CHU Sart-Tilman, 4000 Liège, Belgium
4 Tilman S.A., ZI Sud, Baillonville, Belgium
5 Bioxtract S.A., Parc Scientifique Créalys, Rue Guillaume Fouquet 30, 5032 Les Isnes, Belgium
6 Department of Rheumatology, Hôpital Henri Mondor, Créteil, France
7 Department of Medical Informatics and Biostatistics, CHU Sart Tilman, Liège, Belgium
8 Department of Rheumatology, CHR La Citadelle, Liège, Belgium
Background The management of osteoarthritis (OA) remains a challenge. There is a need not only for safe and efficient treatments but also for accurate and reliable biomarkers that would help diagnosis and monitoring both disease activity and treatment efficacy. Curcumin is basically a spice that is known for its anti-inflammatory properties. In vitro studies suggest that curcumin could be beneficial for cartilage in OA. The aim of this exploratory, non-controlled clinical trial was to evaluate the effects of bio-optimized curcumin in knee OA patients on the serum levels of specific biomarkers of OA and on the evaluation of pain.
Methods Twenty two patients with knee OA were asked to take 2x3 caps/day of bio-optimized curcumin (Flexofytol®) for 3 months. They were monitored after 7, 14, 28 and 84 days of treatment. Pain over the last 24 hours and global assessment of disease activity by the patient were evaluated using a visual analog scale (100 mm). The serum levels of Coll-2-1, Coll-2-1NO2, Fib3-1, Fib3-2, CRP, CTX-II and MPO were determined before and after 14 and 84 days of treatment.
Results The treatment with curcumin was globally well tolerated. It significantly reduced the serum level of Coll2-1 (p < 0.002) and tended to decrease CRP. No other significant difference was observed with the other biomarkers. In addition, curcumin significantly reduced the global assessment of disease activity by the patient.
Conclusion This study highlighted the potential effect of curcumin in knee OA patient. This effect was reflected by the variation of a cartilage specific biomarker, Coll2-1 that was rapidly affected by the treatment. These results are encouraging for the qualification of Coll2-1 as a biomarker for the evaluation of curcumin in OA treatment.
Source : BMC Complementary and Alternative Medicine
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Turmeric and Boswellia Combination Reduces Knee Osteoarthritis Symptoms More Effectively than Celecoxib
Kizhakkedath R. Clinical evaluation of a formulation containing Curcuma longa and Boswellia serrata extracts in the management of knee osteoarthritis. Mol Med Rep. November 2013;8(5):1542-1548.
The degenerative joint disease osteoarthritis (OA) is physically debilitating and significantly impairs quality of life. As the cause of OA remains unknown, current medical treatment is directed towards alleviating pain and restoring movement using nonsteroidal anti-inflammatory drugs (NSAIDs). However, long term use of NSAIDs is associated with significantly increased risk of gastrointestinal, renal, and cardiovascular adverse effects. Turmeric (Curcuma longa) rhizome has been shown to have both anti-inflammatory and antioxidant activity. In clinical trials, boswellia (Indian frankincense; Boswellia serrata) gum resin has shown positive effects in treating both rheumatoid arthritis and OA. This randomized, observational trial tested the efficacy of a turmeric and boswellia (CB) combination in comparison to celecoxib (a standard NSAID) in alleviating the symptoms of knee OA.
The CB combination consisted of 350 mg of turmeric extract standardized to contain 70% curcumin, 17% demethoxycurcumin, 3.5% bisdemethoxycurcumin, and 7.5% turmeric essential oils, and 150 mg boswellia extract consisting of 75% boswellic acids and 10% 3-O-acetyl-11-keto-boswellic acid (AKBA). Although the turmeric constituent curcumin has been shown to have significant anti-inflammatory activity, oral bioavailability is very poor. A formulation providing improved curcumin bioavailability was used in this study. And while the boswellia constituent AKBA also has significant anti-inflammatory activity, the authors point out that most commercial boswellia extracts contain a relatively low concentration of AKBA (~2%). The boswellia extract used in this study was "enhanced" to contain 10% AKBA. The CB combination was provided in 500 mg capsules produced by Arjuna Natural Extracts Ltd.; Aluva, Kerala, India. No other information on the proprietary formula was provided.
In this 12-week study, conducted at Anugraha Medical Centre in Kochi, Kerala, India, 30 patients with OA were randomly assigned to receive either 500 mg of CB twice daily or 100 mg of celecoxib 2 times per day. The study included 8 clinic visits where vital signs, OA symptom scores, and physical exam results were recorded. Included patients were men and women between 18-65 years old diagnosed with moderate OA based upon radiographic evidence. Those with gross OA deformity, severe OA, severe swelling and restricted mobility, rheumatoid or reactive arthritis, other systemic diseases, malnutrition, history of alcohol or drug abuse, and breastfeeding women were excluded.
The OA symptoms scored were joint pain (no pain, mild, moderate, or severe), walking distance (greater than 1,000 m, 500-1,000 m, 100-500 m, or less than 100 m), joint tenderness (no tenderness, improved, same, or worsened), and crepitus or crackling sounds (no crepitus, mild, moderate, or severe). Knee swelling and thigh circumference were quantified using a measuring tape and range of movement was assessed in degrees using a goniometer. Joint warmth (yes, no) and gait (normal or abnormal) were also assessed. To evaluate safety, vital signs, hemogram (laboratory blood parameters), and liver and kidney function were measured at baseline, 6 weeks, and 12 weeks. The authors did not indicate whether they queried patients about possible adverse effects.
In total, 28 patients finished the study, with 1 patient from each group dropping out due to personal reasons or uncontrolled symptoms. At baseline, no significant differences were observed in age, height, weight, body mass index (BMI), temperature, blood pressure, pulse rate, or respiration between the groups. Although pain severity significantly improved from baseline to endpoint (P<0.05) in both groups, no significant differences between groups were observed. However, the number of patients improved was markedly higher in the treatment group; 85.71% of patients were classified in the moderate/severe range at baseline, and at endpoint, only 21.43% of patients were in this category. In the control group, 78.57% of the patients had moderate/severe pain at baseline and 50% still had moderate/severe pain at the endpoint.
Improvement in walking distance was seen in both groups (P<0.05), with 92.86% of those in the treatment group and 85.71% of those in the control group able to walk more than 1000 m at endpoint; however, there were no significant differences between groups. Also, both groups had significantly less joint tenderness at the end of the study (P<0.05). In the treatment group, 85.71% had moderate/severe joint tenderness at baseline, and this decreased to 7.14% of patients at the end of the study. Patients in the control group showed a smaller improvement in joint tenderness, declining from 78.57% at baseline to 21.43% of patients after 12 weeks of treatment. Crepitus improved in both groups from baseline to endpoint (P<0.05); there was also a significant beneficial effect seen in range of movement (P<0.05) in both groups. Swelling, joint warmth, gait, and thigh measurements were not changed in either group. Vital signs, blood parameters, and liver and kidney function remained unchanged. No adverse effects were reported in either group.
The authors conclude that improvements in pain severity, walking distance, and joint tenderness were superior in those taking the CB supplement compared to the NSAID control medication and that CB was comparable to celecoxib in increasing range of movement and decreasing crepitus. They state, "The efficacy and tolerability of [the] CB formulation used in the current study was shown to be superior to those of celecoxib (NSAID) for treating active OA."
The authors hypothesized that the CB formulation would be as effective as celecoxib in reducing OA symptoms, and cause fewer adverse effects. While the effectiveness of the 2 treatments appeared to be comparable, no adverse effects were reported in either group. Studies with a larger sample size are needed to confirm the efficacy of CB and to detect differences in the occurrence rate of adverse effects.
--Amy C. Keller, PhD
Source : American Botanical Council
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Antiarthritic Evalution of Crateva religiosa Extracts
Shyamalendu Tripathy*1, Debashis Pradhan2 & Bimala Tripathy1
1University department of pharmaceutical science, Utkal University, Orissa
2Bhaskara Institute Of Pharmacutical Sciences, Bobali, Andhrapredes
The anti-arthritic potential of Crateva religiosa hook & frost belonging to family Capparidaceae were evaluated by taking complete Freund’s adjuvant (CFA) induced model. Arthritis was induced by injecting 0.1ml of complete Freund’s adjuvant below the plantar aponeurosis of the right hind paw. Treatment with the extracts and standard started on the day of induction of CFA and continue up to 28 days. In this study both the alcoholic and aqueous extracts significantly (p<0.01) decrease the paw edema on 28th day. They also significantly rectified the deranged hematological parameters and biochemical parameters which is observed from the studies.the alcoholic extracts found to show more effect than aquous extracts in the terms of % of inhibition. The study gives a scientific rational to the use of this plant in arthritis and related conditions.
Source : American Journal of Phytomedicine and Clinical Therapeutics
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Influence of a Specific Ginger Combination on Gastropathy Conditions in Patients with Osteoarthritis of the Knee or Hip
Vladimir N. Drozdov, Victoria A. Kim, Elena V. Tkachenko, and Galina G. Varvanina.
Health Care Department, The Central Gastroenterology Scientific Research Institute, Moscow, Russia.
Background: Nonsteroid anti-inflammatory drugs represent an important osteoarthritis (OA) therapy component, but also a leading cause of gastropathy: one of the most frequent and serious OA therapy complications. The aim of the present study was to study the influence of GI health in an OA population receiving either ginger or diclofenac.
Methods: Forty-three (43) patients with confirmed OA (knee and hip) were included in a randomized controlled study. A ginger group of 21 patients (17 women, 4 men) was given a specific ginger combination daily (340 mg EV.EXT 35 Zingiber officinalis extract) for 4 weeks. A diclofenac group (positive control) of 22 patients (18 women, 4 men) received 100 mg diclofenac daily for the same period. Both groups also received 1000 mg glucosamine daily. Gastrointestinal pain and dyspepsia were evaluated according to the severity of dyspepsia assessment (SODA) form. Patients also underwent esophagogastroduodenoscopy (EGDS) including biopsy before and after the treatment. Serum gastrin-17 levels, and stomach mucosa prostaglandins (PG) E1, E2, F2α, and 6-keto PGF1α (PGI2) levels were measured. Arthritic pain was evaluated using the visual analogue scale (VAS) on standing and moving.
Results: The ginger group showed a slight but significantly lowered SODA pain and no change of SODA dyspepsia. EGDS showed significantly increased levels of PGE1, PGE2, and PGF2α in the stomach mucosa. This rise in gastric mucosa PG levels correlated with an increase in serum gastrin-17. On the other hand, the diclofenac group showed increased SODA pain and dyspepsia values with a corresponding significant decrease of stomach mucosa prostaglandins and general negative stomach mucosa degeneration. Both groups showed a relevant and significantly lowered VAS pain both on standing and moving.
Conclusions: The ginger combination is as effective as diclofenac but safer in treating OA, being without effect on the stomach mucosa. The increased mucosal PGs synthesis in the ginger group supports an increased mucosa-protective potential.
Source : The Journal of Alternative and Complementary Medicine
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Arthritis: Sun's Rays May Cut Risk in Women
More intense sunlight exposure was linked with a decreased incidence of rheumatoid arthritis (RA) among women in the original Nurses' Health Study (NHS), although the more common use of sunscreen likely attenuated the association in a later cohort, researchers found.
In NHS, which began in 1976, women (ages 30 to 55) living in states with the highest ultraviolet B (UVB) intensity had a 21% lower risk for RA compared with those living in states with low UVB levels (hazard ratio 0.79, 95% CI 0.66 to 0.94, P=0.005 for trend), according to Elizabeth Arkema, PhD, and colleagues from Harvard University.
But in NHSII, initiated in 1989 in women ages 25 to 42, no significantly lower risk was seen (HR 1.12, 95% CI 0.87 to 1.44, P=0.37 for trend), the researchers reported online in Annals of the Rheumatic Diseases.
"The later birth cohort of NHSII participants (born between 1946 and 1964) were more likely aware of the dangers of sun exposure and, perhaps, had more sun-protective behavior, making residential UVB not as good a proxy for actual sun exposure in NHSII," they suggested.
Epidemiologic studies have found a correlation between an increased incidence of RA and other autoimmune diseases with higher latitude of residence.
In addition, experimental studies have demonstrated immunosuppressive effects of UVB, such as through influences on T-cells and cytokines.
Exposure to UVB also increases vitamin D synthesis in the skin, which, in turn, has immunomodulatory properties.
To examine a possible role for sunlight exposure on RA risks, Arkema and colleagues averaged cumulative UVB flux data for 106,368 women in NHS and 115,561 women in NHSII according to the state in which they lived.
UVB flux is a measure that reflects exposure intensity based on altitude, latitude, and typical cloud cover patterns, and is expressed in Robertson-Berger units.
This measure shows considerable variability in the U.S., ranging from 196 R-B units in sunny states such as Arizona and Hawaii to only 93 units in Oregon and Alaska.
Information on residence, health, diet, and lifestyle was acquired every 2 years from participants in both cohorts.
A total of 933 women in NHS were diagnosed with RA, as were 381 in NHSII.
The mean age at the time of RA diagnosis was earlier in NHSII, at 47 years, compared with 58.7 years in NHS.
The absolute risk over 20 years for RA in NHS among women in the states with the highest levels of UVB was 0.7% compared with 1.2% in those living in the lowest levels, for a risk difference of 0.5% (95% CI 0.2 to 0.8).
In contrast, the absolute risk was 0.5% for both highest and lowest levels in NHSII, giving a risk difference of 0% (95% CI −0.2 to 0.2).
Similar findings of decreased risk for high exposure in NHS though not in NHSII were seen both for exposure levels at birth and at age 15.
It thus remains unclear if the important window for UVB exposure is in childhood or adulthood.
Further analyses found no significant heterogeneity according to skin type, vitamin D intake, or physical activity and body mass index.
There also was no greater effect for the highest level of cumulative UVB exposure, above 164 R-B units, or the highest level of vitamin D intake, at 400 IU per day or more.
And while NHSII was a younger cohort, when risks were calculated for women in that cohort ages 52 and above, the hazard ratio was similar to that seen in NHS.
Additional adjustment for factors such as regional socioeconomic factors and access to care had little effect on risk estimates, but the researchers acknowledged that there may have been additional environmental or behavioral factors that could influence their results.
These findings add to the increasing evidence that more intense sun exposure lowers the risk of RA, the researchers stated.
"The mechanisms are not yet understood, but could be mediated by cutaneous production of vitamin D and attenuated by use of sunscreen or sun avoidant behavior," Arkema and colleagues wrote.
They called for additional research to explore UVB dose intensity and timing of exposure
Source : MedPage Today via Annals of the Rheumatic Diseases
Arkema E, et al "Exposure to ultraviolent-B and risk of developing rheumatoid arthritis among women in the Nurses' Health Study" Ann Rheum Dis 2013; DOI: 10.1136/annrheumdis-2012-202302.
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Topical Olive Oil Alleviates Pain and Improves Physical Function in Osteoarthritis Patients
Bohlooli S, Jastan M, Nakhostin-Roohi B, Mohammadi S, Baghaei Z. A pilot double-blinded, randomized, clinical trial of topical virgin olive oil versus piroxicam gel in osteoarthritis of the knee. J Clin Rheumatol. March 2012;18(2):99-101.
Many people suffer from osteoarthritis (OA), with the knee being the joint most affected. Patients who do not respond well to conventional medical therapies, including topical nonsteroidal anti-inflammatory drugs (NSAIDs) and salicylates, often turn to complementary and alternative medicines. One of the traditional methods of managing knee pain in Iran, the home of these authors, is to apply topical olive (Olea europaea) oil. The compounds of olive oil thought to contribute to its observed health benefits include oleic acid, phenolics, and squalene,1 while the secoiridoid derivative, (-)-oleocanthal, has been shown to have NSAID properties.2 The authors conducted a pilot, prospective, comparative, randomized, double-blinded trial of topical virgin olive oil therapy versus the NSAID piroxicam gel in the treatment of knee OA.
The study was conducted in the rheumatology clinic of Imam Hospital, Ardabil University of Medical Sciences, in Ardabil, Iran, from April 2008 to April 2010. The subjects included women aged between 40 and 85 years with a diagnosis of OA of 1 or both knees according to the American College of Rheumatology criteria and with a flare of pain following prior therapy withdrawal of an oral NSAID or acetaminophen (used at least 3 days weekly during the previous month).
At the screening visit, knee pain was scored on the 20-point scale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) of pain. At that time, the subjects discontinued any current therapy for a 1-week washout period. At the baseline visit, pain was scored again. Eligible subjects had to have a pain flare and a pain subscale score of ≥9 on the WOMAC scale. A flare was defined as an increase in total score of at least 2 between the screening and baseline visits.
Included subjects were then randomized to apply piroxicam gel (n=36) or olive oil (n=35) for 4 weeks. They returned to the clinic on weeks 1, 2, 3, and 4 for assessment of efficacy, safety, and compliance. The piroxicam gel (Iran Najo Co.; Tehran, Iran) contained 0.5% piroxicam in a vehicle composed of carbomer 934, ethanol, propylene glycol, hydroxypropyl, α-methyl cellulose, sodium edetate, benzyl alcohol, diisopropanolamine, and purified water. The virgin olive oil was prepared directly from fruits of olive trees grown in Gilan Province in Iran. Both were packaged in identical 60 gram tubes. The subjects were instructed to apply 1 g of the medications 3 times daily on one primary affected knee to assess efficacy; the other knee, if treated, was only evaluated for safety.
The primary outcome measure was the change in scores on the WOMAC pain subscale from baseline to weeks 1, 2, 3, and 4. The secondary outcome measure was change in physical function from baseline to final assessment in the affected knee on the 68-point WOMAC physical function subscale.
Of the 71 subjects enrolled in the study, 58 completed it. Of the 6 piroxicam and 7 olive oil dropouts, 5 were due to protocol deviations and 7 due to lack of therapeutic effect. Up to 4 acetaminophen tablets (325 mg each) daily were allowed during weeks 1-3 for residual pain. No significant group differences were found for age, weight, height, or WOMAC subscales at baseline.
The authors report that topical olive oil was superior to piroxicam gel in the WOMAC pain subscale at weeks 2, 3, and 4. The mean change on the pain subscale for olive oil was a decrease of 7.48 between weeks 0 and 4 (P<0.001). In the piroxicam group, the mean score decreased by 2.73 (P<0.001). Although pain intensity was significantly decreased from baseline in both groups between weeks 0 and 4, a more significant decrease was reported in the olive oil group (P<0.001). There were no significant differences in daily acetaminophen use between the groups.
Regarding the secondary outcome measures, the olive oil showed significant superiority to piroxicam in the WOMAC physical function subscale at weeks 2, 3, and 4. A greater mean decrease in scores from baseline on the physical function subscale was noted for subjects treated with olive oil (-23.63) compared with those in the piroxicam group (-10.97) (P<0.001). One patient reported an adverse effect: skin allergy after virgin olive oil application.
Although the composition of olive oil is complex, the component oleocanthal may be responsible for some of the beneficial effects of the olive oil on knee pain. The presence of several types of antioxidants and anti-inflammatory agents in olive oil may also be attributed to its effects.
Among the study's limitations are the small sample size, the short duration, and the fact that it was not placebo-controlled. "Further studies should be conducted to evaluate the long-term effects of virgin olive oil on knee OA in larger populations," conclude the authors.
Overall, the findings of this study suggest that treatment for knee OA with topical virgin olive oil is associated with greater improvement in all outcome measures compared to treatment with piroxicam gel. The differences increased over time in favor of the olive oil.
Source : AmericaN Botanical Council
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Special Curcumin Extract from Turmeric Shows Promise in Rheumatoid Arthritis Patients in Pilot Trial
by Risa N. Schulman
Reviewed: Chandran B, Goel A. A randomized, pilot study to assess the efficacy and safety of curcumin in patients with active rheumatoid arthritis. Phytother Res. March 9, 2012. [Epub ahead of print]. doi: 10.1002/ptr.4639.
Rheumatoid arthritis is a chronic systemic inflammatory disorder that is distinguished from other forms of arthritis by the joint destruction that is its prominent feature. Typically, 30% of patients do not respond to the classic forms of treatment. Curcumin, the major active constituent of the spice turmeric (Curcuma longa, Zingiberaceae), has been shown to modulate numerous pathways related to inflammation. This randomized, single-blind, pilot study examined the efficacy and safety of a curcumin extract in comparison to, and in combination with, diclofenac sodium (a pharmaceutical non-steroidal anti-inflammatory drug [NSAID]) in patients with mild-to-moderate rheumatoid arthritis (RA).
The study was conducted at Nirmala Medical Centre in Muvattupuzha, Kerala, India, and included 45 patients (38 females and 7 males; mean age=47.88 years) with RA according to the revised 1987 American College of Rheumatology (ACR) criteria (with RA functional class I or II) and Disease Activity Score 28 (DAS28) > 5.1. Patients were excluded if they were taking NSAIDs or other anti-arthritic therapies, had any complicating surgeries or diseases, were pregnant or nursing, or had a history of substance abuse. Patients were divided into 3 groups: curcumin extract (500 mg BCM-95®; Arjuna Natural Extracts; Kochi, Kerala, India; imported and sold in the United States as CuraMed® by EuroPharma; Green Bay, WI), diclofenac sodium (50 mg; no source given), or both in combination; treatments were taken twice a day for 8 weeks. Neither the article nor the manufacturer’s website describes standardization.
Data on demographic characteristics, medical history, and medications were collected at baseline. Body weight, blood pressure, and heart rate were recorded, and hematology, blood chemistry, C-reactive protein (CRP), antistreptolysin-O (ASO), and blood sugar tests were performed. Each patient underwent an X-ray with an anteroposterior (AP) view of chest/hands/wrist/foot and 12-lead electrocardiography as well as a 28-joint assessment for tender joint count, swollen joint count, and duration of morning stiffness.
The primary endpoint was reduction in DAS28, a composite index based on the assessment of 28 joints, the erythrocyte (red blood cell) sedimentation rate (ESR), and visual analog scales (VAS) on which the patient scored his/her global assessment of disease activity. The secondary endpoints included ACR criteria scores. The ACR measures the improvement in tenderness or swollen joint counts and improvement in three of 5 parameters: patient global assessment, physician assessment, pain scale disability, functional questionnaire – HAQ (Health Assessment Questionnaire), and acute phase reactant (such as ESR).
There was no significant difference in any baseline characteristics between the groups. Thirty-eight patients completed the study and were included for efficacy analyses; all 45 patients were included in safety assessments. No explanation is given as to the reasons 7 patients did not complete the study.
There was a statistically significant change in DAS28 scores compared to baseline of similar proportion for all 3 treatment groups after 8 weeks (all P<0.05). There was no significant difference among the groups. Likewise, each group had a statistically significant difference in the ESR and VAS (all P<0.05) compared to baseline, but not among groups; curcumin extract had the highest percentage change of the 3 groups for VAS (59.9%). There was also a statistically significant change in ACR scores in all 3 treatment groups (all P<0.05), but no difference among them. The authors report that the percentage change in ACR was greatest for curcumin. CRP showed a significant change only in the curcumin group (P<0.05).
Adverse events were reported more frequently in the diclofenac sodium group and included itching and swelling around the eyes, dimness of vision, and worsening of the condition. Adverse events reported in the curcumin group were mild fever and throat infection (which are not necessarily associated with the use of the curcumin).
This pilot study shows that BCM-95 curcumin reduced DAS28 and ACR scores in patients with RA alone or in combination with diclofenac sodium. It also showed that intake levels of 500 mg twice daily for 8 weeks yielded few adverse effects. The mechanism for this action is not known but is purported to be due to the effect of curcumin on multiple signaling pathways involved with pain and inflammation. The authors reported that BCM-95 curcumin was selected for use in this study based on its enhanced absorption, which has been shown in 2 previously published human studies to have up to 7 times increased absorption than generic 95% curcumin turmeric extracts based on area under the curve (AUC) and 10 times the serum peak of generic 95% curcumin extracts.1,2
The authors conclude by asserting that BCM-95 curcumin extract was the superior treatment in this study, based on its efficacy equaling the prescription drug diclofenac sodium on DAS28 and ACR scores, combined with its superior safety and lower adverse effect profile. What can be said is that this proprietary curcumin extract had a similar effectiveness to the prescription drug diclofenac sodium with few adverse side effects. Larger studies will help to shed light on these findings.
—Risa Schulman, PhD
1. Antony B, Merina B, Iyer VS, et al. A pilot cross-over study to evaluate human oral bioavailability of BCM-95 CG (Biocurcumax), a novel bioenhanced preparation of curcumin. Ind J Pharm Sci. 2008;70(4):445-449.
2. Benny M, Antony B. Bioavailability of BioCurcumax™ (BCM-95™). Spice India. September, 2006:11-15.
Source : ABC
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Comparison of the effects of curcuminoid from Curcuma domestica Val. rhizome extract and diclofenac sodium on the liver function of patients with osteoarthritis
Nyoman Kertia1*, Ahmad Husain Asdie2, Wasilah Rochmah3 and Marsetyawan4
1Rheumatology Department of Internal Medicine, Faculty of Medicine, Gadjah Mada University/Dr. Sardjito Hospital, Yogyakarta, 55286, Indonesia.
2Endocrinology Department of Internal Medicine, Faculty of Medicine, Gadjah Mada University/Dr. Sardjito Hospital, Yogyakarta, 55286, Indonesia.
3Geriatric Department of Internal Medicine, Faculty of Medicine, Gadjah Mada University/Dr. Sardjito Hospital, Yogyakarta, 55286, Indonesia.
4Department of Histology and Cell Biology, Faculty of Medicine, Gadjah Mada University, Yogyakarta, 55286, Indonesia.
Osteoarthritis is the most frequent joint disease worldwide. Patients with osteoarthritis mostly use non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac sodium for reducing pain. Diclofenac sodium frequently disturbs the liver function. Curcuminoid has an anti-inflammatory activity and some references state that curcuminoid protects the liver function. The purpose of this study was to compare the effects of curcuminoid from Curcuma domestica Val. rhizome extract and diclofenac sodium on the liver function of patients with osteoarthritis. A total of 80 patients with knee osteoarthritis were enrolled. Subjects were divided randomly into two groups; a group received 30 mg of curcuminoid from C. domestica Val. 3 times daily (curcuminoid group) and the other received 25 mg of diclofenac sodium 3 times daily (diclofenac group). Assessment of results includes serum levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) performed before and after 4 weeks of treatment. In the curcuminoid group, there was no significant decrease of AST serum level (p < 0.15) and ALT serum level (p < 0.41), whereas in the diclofenac group, there was no significant increase of AST serum level (p=0.05) and significant increase of ALT serum level (p<0.01). The increase of serum AST and ALT level in the diclofenac group were significantly different as compared to the decrease of the levels in the curcuminoid group. This means that diclofenac sodium disturbs liver function, while curcuminoid from C. domestica Val. rhizome extract improves the liver function of patients with osteoarthritis.
Source: Journal of Pharmacognosy and Phytotherapy Vol. 4(5), pp. 62 - 65, August 2012 DOI: 10.5897/JPP11.079
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Acupuncture Offers Low-Cost Alternative to Knee Surgery for Osteoarthritis, Research Finds
Acupuncture can relieve the pain of knee osteoarthritis and offer a low cost alternative to surgery for the condition, finds research published online in Acupuncture in Medicine.
The researchers base their findings on 90 patients with knee osteoarthritis, who were referred for group acupuncture to two knee pain clinics in St Albans, Hertfordshire, in 2008 and subsequently monitored for two years.
The clinics were set up in 2008 for NHS patients, and run in two GP practices by specially trained acupuncture nurses, to see whether this could improve care, while reducing costs, and offer a viable alternative to referrals for expensive knee replacement surgery (http://youtu.be/HX3ziJ_DNCQ?hd=1).
This type of surgery works well, and provides value for money, say the authors. But it is not suitable for everyone, and as many as one in seven patients experience severe pain a few years after the procedure.
It also costs £5,000 a pop, and knee osteoarthritis is common, causing significant pain in 17% of the UK population over the age of 50, they add.
Out of 114 patients who were offered acupuncture for osteoarthritic knee pain in 2008, 90 accepted and were treated in the clinics. Their average age was 71. All the patients referred to the clinics had severe symptoms -- constant pain, including at night, and inability to walk far -- and would have been eligible for surgery.
Fifty patients said they would be prepared to have surgery; four said they would only have the operation as a last resort; and 29 said they did not want surgery.
They were given acupuncture once a week for a month after which the frequency was reduced to a session every six weeks.
Forty one patients were still attending the clinics after a year, and 31 were still receiving treatment after two years. Each patient received an average of 16.5 treatments.
A validated score (MYMOP), used to measure symptom control, functional capacity, and wellbeing, showed clinically significant improvements in pain levels, stiffness, and functional capacity after one month of treatment. These improvements continued throughout the two year monitoring period, as assessed by MYMOP at six monthly intervals.
Based on the assumption that only two thirds of patients would take up an offer of acupuncture, the authors calculate that the service could save the NHS around £100,000 a year. Each treatment costs the NHS £20.
The authors also looked at the rates of total knee replacements for the three neighbouring commissioning groups after the service had been introduced.
They found that the group that had commissioned the service, which includes 13 general practices serving 180,000 patients, had the lowest rate, and that this was 10% lower than one of the other groups by 2011.
A second small study in the journal shows that group acupuncture was popular with both nurses and patients, and in an accompanying podcast (http://snd.sc/NaCdbu), a patient who underwent the treatment describes what a difference it has made to her life.
Source : Science Daily via
Group acupuncture for knee pain: evaluation of a cost-saving initiative in the health service. Acupuncture in Medicine, 2012; DOI: 10.1136/acupmed-2012-010151
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Siginificant Benefits of Yoga in People With Rheumatoid Arthritis, Study Shows
Individuals with rheumatoid arthritis who practice yoga showed statistically significant improvements in disease activity, according to a small study presented at the EULAR 2011 Annual Congress.
The results of the study conducted in the United Arab Emirates (UAE) among 47 patients (26 yoga patients and 21 controls) demonstrate that patients who completed 12 sessions of Raj yoga which is one of the gentler styles of yoga, combining exercise and breathing techniques showed significant improvements in disease activity scores (DAS28) of p=0.021 and health assessment questionnaire's (HAQ†) of p=0.0015. However there was no statistically significant improvement on the quality of life scale (QoL).
"Most patients with RA do not exercise regularly despite the fact that those who do report less pain and are therefore more physically active," said Dr Humeira Badsha MD Rheumatologist and founder of the Emirates Arthritis Foundation, Dubai, UAE. "While our study has been conducted in a small group of patients the results show clear benefits for patients who regularly practice Raj yoga. We believe that practicing yoga longer term could in fact result in further significant improvements and hope our study drives further research into the benefits of yoga in RA."
Patients were recruited by email through the Emirates Arthritis Foundation RA database (mean age of yoga group 44 years, mean age of control group 46.2 years, 80% female). Demographic data, disease activity indices, health assessment questionnaire (HAQ) and SF-36 (a standard patient survey commonly used to calculate patient quality of life) were documented at enrolment and after completion of 12 sessions of yoga.
Results of a separate study show the positive effects of yoga on the quality of life in patients with Fibromyalgia, a long-term condition which causes extreme pain all over the body.
Results of one further study investigating the effects of yoga on the QoL of patients with fibromyalgia, demonstrated that QoL scores, after an eight session classical yoga program which combines gentle yoga postures, breathing techniques and meditation, were better than scores obtained before the program (p<0.05) along with a significant decrease in the anxiety levels of patients (p<0.05). As anxiety is often a key symptom in patients with this condition, this study represents a positive step in improving the lives of people suffering from fibrolmyalgia.
Source : Science Daily
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Joint Status Improved by Lemon Verbena Extract Combined with Fish Oil
Caturla N, Funes L, Pérez-Fons L, Micol V.
Arthritis is characterized by inflammation of the joints, and there are 2 general types of the disease. Osteoarthritis (OA) is associated with age-related joint degeneration, while rheumatoid arthritis (RA) is caused by autoimmune joint inflammation. Cartilage destruction, synovial fluid disruption, mitochondrial dysfunction, and other joint-related problems have been found to be caused by reactive oxygen and nitrogen species (RONS). Many plants used medicinally have antioxidant activity, and many plant antioxidant compounds alleviate diseases caused by inflammation.
Lemon verbena (Aloysia citriodora syn. A. triphylla and Lippia citriodora), used traditionally for a variety of ailments, contains the potent antioxidant and anti-inflammatory phenylpropanoid compound verbascoside. In addition, the long chain omega-3 polyunsaturated fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), found in cold-water fish oil, have been shown to affect the immune system. This double-blind, placebo-controlled, randomized study investigated the effects of a mixture of lemon verbena extract and fish oil omega-3 fatty acids on patients with joint pain and dysfunction. In addition, the antioxidant capacity of both the extract and treatment mixture was assessed in vitro.
The lemon verbena extract was dissolved with water (5 mg/ml), and the verbascoside content of the extract was analyzed using high-performance liquid chromatography (HPLC). Antioxidant activity was measured using the oxygen radical absorbance capacity (ORAC) assay and data expressed as µmole of Trolox equivalents (TE) per gram; in this particular assay, a higher ORAC value indicates stronger antioxidant activity.
Included patients were diagnosed by a physician as having joint discomfort and pain in knees, hips, elbows, hands, or shoulders for 3 months or more. Patients were excluded if they used medication other than for high cholesterol, or antihypertonic or antiarrhythmic agents. Patients were also excluded if they had plant, herbal medicine, vitamin, or mineral allergies. Patients were randomized to either supplement (n=23) or placebo (n=22) groups for the 9-week study. A capsule of the supplement (0.6 g) consisted of 370 mg of fish oil powder containing a ratio of 10:8 EPA to DHA, and 230 mg of lemon verbena extract containing 14% w/w verbascoside. All patients took 6 capsules daily of placebo or supplement, 2 before each meal from week 1 to week 5. At the beginning of week 6, patients took 3 capsules per day before meals until week 9. The dose per day of verbascoside from weeks 1-5 was 193 mg, and 97 mg for weeks 6-9.
The primary endpoints were joint pain, stiffness, and function. These were assessed using the Western Ontario McMaster (WOMAC) and Lequesne's surveys. The WOMAC questionnaire is designed to measure pain/stiffness and physical dysfunction, while Lequesne's assesses pain, discomfort, maximum distance walked, and daily activities. Reduced severity of these arthritis factors is indicated in a low score for both questionnaires. Surveys were completed by patients at baseline and at least once per week during the study.
It was found that verbascoside was the most common phenylpropanoid in the lemon verbena extract and occurred at 14.75 ± 0.85% w/w. Isolated verbascoside had an ORAC value of 11,710 ± 106 µmol TE/g, while the extract was 5,183 ± 300 µmol TE/g. The total supplement was found to have antioxidant activity of 1,065 ± 122 µmol TE/g. It is surmised that excipients associated with the omega-3 fatty acids may have interfered in the assay, resulting in a value lower than expected. Of the 45 total patients randomized, 31 completed the study (n=12 for the placebo group and n=19 in the supplement group). No significant differences were seen between groups at baseline, and the majority of patients maintained normal physical activity. Only 1 adverse side effect was found in each group; these patients were dropped from the study, supplementation discontinued, and no complications ensued.
The WOMAC scores in the supplement group declined steadily throughout the study, and the pain/stiffness and function scores of the test first significantly differed from the placebo group at weeks 3 (P≤0.01) and 4 (P≤0.05), respectively. Also, the total WOMAC score of the supplement group at 9 weeks was 53% lower than the baseline score. No significant changes were observed in the WOMAC score of the placebo group. In addition, the Lequesne's score of the supplement group was significantly different from the placebo group at week 4 (P≤0.05) and remained significant from weeks 5-9 (P≤0.01). By the end, the score had decreased by 78% as compared to the baseline score. No significant differences were seen in the Lequesne's scores of the placebo group.
The combination supplement of lemon verbena extract and omega-3 fatty acids significantly improved arthritis symptoms in this study. Many previous studies have shown that a diet rich in antioxidants may improve disorders caused by exercise-induced free radicals and other RONS-caused inflammation problems. Lemon verbena extract and compounds therein demonstrate antioxidant activity, and omega-3 fatty acids have been shown to benefit those suffering from joint problems; therefore, this tested mixture is worthy of future investigation into the treatment of arthritis and other inflammation diseases.
Source : American Botanical Council
via A randomized, double-blinded, placebo-controlled study of the effect of a combination of lemon verbena extract and fish oil omega-3 fatty acid on joint management. J Altern Complement Med. November 2011;17(11):1051-1063.
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Ginger compress therapy for adults with osteoarthritis
Tessa Therkleson PhD RN
Director of Nursing RATO Health, Lower Hutt, New Zealand.
This paper is a report of a study to explicate the phenomenon of ginger compresses for people with osteoarthritis.BackgroundOsteoarthritis is claimed to be the leading cause of musculoskeletal pain and disability in Western society. Management ideally combines non-pharmacological strategies, including complementary therapies and pain-relieving medication. Ginger has been applied externally for over a thousand years in China to manage arthritis symptoms.
Husserlian phenomenological methodology was used and the data were collected in 2007. Ten purposively selected adults who had suffered osteoarthritis for at least a year kept daily diaries and made drawings, and follow-up interviews and telephone conversations were conducted.
Seven themes were identified in the data: (1) Meditative-like stillness and relaxation of thoughts; (2) Constant penetrating warmth throughout the body; (3) Positive change in outlook; (4) Increased energy and interest in the world; (5) Deeply relaxed state that progressed to a gradual shift in pain and increased interest in others; (6) Increased suppleness within the body and (7) More comfortable, flexible joint mobility. The essential experience of ginger compresses exposed the unique qualities of heat, stimulation, anti-inflammation and analgesia.
Nurses could consider this therapy as part of a holistic treatment for people with osteoarthritis symptoms. Controlled research is needed with larger numbers of older people to explore further the effects of the ginger compress therapy.
Source : J Adv Nurs. 2010 October; 66(10): 2225–2233
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Chondroitin Eases Pain, Boosts Function in Arthritic Hands
Six months of treatment with chondroitin led to significant improvements in pain and function among patients with osteoarthritis (OA) in their hands, a single-center randomized trial found.
Global hand pain rated on a 100-mm visual analog scale fell by 20 mm for patients taking chondroitin, compared with 11.3 mm for patients receiving placebo, for a between-group difference in change of −8.7 mm (P=0.016), according to Cem Gabay, MD, of University Hospitals of Geneva in Switzerland, and colleagues.
In addition, scores on the 30-point Functional Index for Hand OA decreased by 2.9 points in the chondroitin group and by 0.7 points in the placebo group, giving a between-group difference in change of −2.14 (P=0.008), the researchers reported in the November Arthritis & Rheumatism.
More than half of people older than 60 experience hand OA, with the most commonly involved joints being the distal and proximal interphalangeal, the trapeziometacarpal, and the thumb interphalangeal.
But the therapeutic options are few and data on the efficacy of these therapies are scarce, the authors stated.
Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are helpful for pain relief, but they can cause gastrointestinal side effects and their long-term use is hampered by potentially serious cardiovascular adverse effects.
Topical anti-inflammatory agents also can be somewhat effective, but are not generally convenient for use in a chronic condition.
Acetaminophen is another option, although in the population most affected by hand OA, this drug can have negative effects on blood pressure.
To explore the potential clinical benefits of chondroitin, Gabay and colleagues enrolled 162 patients with severely symptomatic OA, assigning them to six months of daily chondroitin (800 mg) or placebo. Chondrotin is marketed as a dietary supplement in the U.S., but licensed as a prescription OA treatment in much of Europe.
The study drug contained purified chondroitin sulfate derived from fish sources.
Patients all had baseline pain scores of at least 40 mm on the 100-mm visual analog scale and had at least two joints with radiographic evidence of OA.
They were allowed to take rescue acetaminophen in maximum daily doses up to 4 grams.
Their mean age was 63, and two-thirds were women.
Mean pain score at baseline in the target hand was 54 and mean functional score was 11.
The mean number of painful flares during the previous year was 35 in the chondroitin group and 30 in the placebo group.
Patients who had erosive arthritis and involvement of the basal thumb joint had worse functional scores at baseline, but their pain scores were not significantly increased.
These features did not influence treatment outcome, however, on multivariate analysis.
A secondary outcome favoring chondroitin was duration of morning stiffness, which decreased by 4.8 minutes in the active treatment group but increased by 0.3 minutes in the placebo group (between-group difference in change −5.1, P=0.031).
Physician global assessment of efficacy increased during the trial for the chondroitin group, while between-group differences were not seen on acetaminophen use or change in hand grip strength.
Adverse events were reported by 42.5% of the chondroitin patients and by 41.5% of the placebo group.
Two patients in each group experienced serious adverse events, with only one case of abdominal pain in a placebo patient being considered possibly related to treatment.
Three patients in the active treatment group withdrew because of adverse events, as did eight patients in the placebo group.
At the end of the study, tolerability was rated as good or excellent in 96.3% of the active treatment patients and 90.8% of placebo patients.
Chondroitin has not been directly compared with NSAIDs, but the overall magnitude of effect appears to be similar, according to the researchers.
The effect size for pain was "relatively modest," but the improvement in functional scores seen at six months "is indicative of a positive clinical effect of [chondroitin] in this study population," they observed.
They noted that the advantage of anti-inflammatory drugs is prompt relief of symptoms, with the drawback of long-term safety concerns.
"In contrast, the benefits of [chondroitin] appear to take several months to develop, but with hardly any side effects, and this could help reduce the need for long-term [NSAID] therapy in patients with hand OA," they explained.
Limitations of the study included an inadequate numbers of patients to detect differences in some secondary outcomes and in subgroups of patients. Also, a restriction to patients with severe disease.
Source : Medpage Today
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Turmeric Extract Comparable to Ibuprofen in Treating Knee Osteoarthritis Symptoms
Reviewed: Kuptniratsaikul V, Thanakhumtorn S, Chinswangwatanakul P, Wattanamongkonsil L, Thamlikitkul V.
Efficacy and safety of Curcuma domestica extracts in patients with knee osteoarthritis. J Altern Complement Med. 2009;15(8):891-897.
Osteoarthritis (OA), a degenerative joint disorder, is a common cause of disability for both men and women. Nonsteroidal antiinflammatory drugs (NSAIDs) are the most common form of treatment for relieving pain associated with OA, but they can cause serious adverse side effects that impact gastrointestinal, renal, and cardiac health. Curcumin present in turmeric (Curcuma longa, syn. C. domestica, Zingiberaceae) extracts has been reported to have anti-inflammatory and antioxidant properties. Researchers from Mahidol University in Bangkok, Thailand conducted a study to determine the efficacy and safety of a turmeric extract in reducing pain and improving function in patients with knee OA.
Conducted at Siriraj Hospital in Bangkok, from April 2005 to May 2006, the study included adult subjects who had primary knee OA according to the American Rheumatism Association criteria. To be included in the study, patients had to have knee pain and radiographic osteophytes, as well as at least 1 of the following characteristics: being older than 50 years of age, suffering from morning joint stiffness lasting less than 30 minutes, and/or experiencing crepitus (crackling in joints) on motion. Patients reporting a pain score of ≥ 5 of 10 in a numerical rating scale were recruited.
The patients were asked to discontinue their medications for knee OA 1 week before randomization. All patients were randomly allocated to receive either ibuprofen (400 mg twice daily) or turmeric extract (500 mg curcuminoids 4 times daily) for 6 weeks.
According to the authors, the turmeric extracts were produced by the Thai Government Pharmaceutical Organization under the Good Manufacturing Practices standard. Dried turmeric rhizomes were ground into powder. The turmeric powder was extracted with ethanol and then evaporated at low pressure to obtain ethanolic extracts containing oil and curcuminoids. The oil was then removed. Each capsule of extract contained 250 mg curcuminoids.
The patients were assessed every 2 weeks. The main outcomes were pain on level walking and pain on stair climbing, measured by a numerical rating scale, as well as knee functions assessed by the time spent on a 100-meter walk and going up and down 10 steps.
All patients had blood tests assessing complete blood count, liver function, and renal function at week 0 and week 6. At week 6, the patients’ satisfaction with treatment was evaluated by a 5-category scale (high, moderate, little, same, or dissatisfaction).
Of 190 patients screened, 107 were selected for the study; 52 were randomly assigned to the curcuminoid group and 55 to the ibuprofen group. Of those, 45 patients in the curcuminoid group and 46 patients in the ibuprofen group completed the study. Most of the patients were overweight (average body mass index greater than 25) elderly women. The duration of symptoms before entering the trial was approximately 20 months. Half of the patients had bilateral knee OA. At baseline, the mean pain scores on level walking and on the stairs, as well as the time spent on the 100-meter walk and on the flight of stairs, were similar between the 2 groups.
The authors report that the mean scores of all outcomes in both groups at week 6 were significantly improved when compared with the baseline values. For example, from week 0 to week 6, the scores for pain on level walking dropped from 5.3 ± 2.3 to 2.7 ± 2.5 for the curcumin group and from 5.0 ± 1.9 to 3.1 ± 2.3 in the ibuprofen group. There was no significant difference in those parameters between the 2 groups, except that pain on stair climbing was less for those taking curcuminoids (P = 0.016). Also, the curcuminoid group seemed to spend less time on the 100-meter walk and going up and down a flight of stairs. No significant differences were found for adverse events between the 2 groups, with dyspepsia (stomach upset; curcuminoids 20.8%, ibuprofen 26.9%) most common. Interestingly, many patients in the curcuminoid extract group who experienced bloating symptoms and passing gas described these symptoms as beneficial gastrointestinal effects, whereas those in the ibuprofen group reported gastrointestinal irritation symptoms.
Regarding satisfaction, most patients rated themselves as having moderate to high satisfaction (91.1% in the curcuminoid group, 80.4% in the ibuprofen group). The patients’ satisfaction with treatment was not statistically significantly different (P = 0.15) between the groups. The patients in the ibuprofen group had better compliance to the treatment regimen than those in the curcuminoid extract group (90.1% versus 82.8%, P = 0.001). This finding was attributed by the researchers to the fact that ibuprofen was given twice a day, whereas curcuminoid extract had to be taken 4 times a day.
These results suggest that curcuminoid extracts of turmeric might be as effective as ibuprofen in alleviating knee pain and improving knee functions, with a trend toward a greater effect in patients receiving curcumin extracts. However, the wide range of 95% confidence interval (CI) indicated that the study had an inadequate sample size; the proper sample size should be 70 patients per groupThe authors recommend more studies with an adequate sample, a higher dose of ibuprofen in the comparison group, and a double-blind technique to demonstrate the efficacy of turmeric extracts in alleviating knee pain and improving knee function.
Source : Herbalgram
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Special Turmeric Extract Benefits Osteoarthritis Patients
A new clinical trial supports the benefits to people with osteoarthritis who used a unique extract of turmeric (Curcuma longa).1 Scientists in Italy have studied the pain-relief, increased flexibility, and other effects of a special, patented extract of the roots of turmeric, the flavorful spice that has been used for centuries as a traditional remedy. Turmeric formulations have shown a wide range of safety and significant scientific and clinical benefits in recent animal research and human clinical trials.2,3The characteristic yellow color of turmeric, which is found in many yellow mustards and yellow curry preparations, derives from compounds known collectively as curcuminoids, whose most abundant member is curcumin. Curcumin is difficult to absorb into the human bloodstream from the gastrointestinal tract when consumed orally.4
Researchers in Italy selected 50 patients with X-ray diagnosed osteoarthritis in either one or both knees to evaluate if the special turmeric formulation called Meriva® could provide more benefits to their standard medical therapy. In this trial, the patients were split into two groups: the first one received standard medical treatment as determined by patients’ physicians, while patients in the second group added the special curcumin extract to their standard medical treatment.
After 90 days, the following benefits were observed: Compared to the controls, patients in the Meriva group experienced a 58 percent decrease in their overall pain, stiffness and physical functionality as measured by the widely used medical scoring method developed by Western Ontario and McMaster Universities (WOMAC). In addition, the Social and Emotional Index (SEI) score resulted in a greater than 300 percent improvement in Meriva patients compared to patients not taking the curcumin extract. Blood tests indicated that in patients having elevated levels of C-reactive protein (CRP), a 16-fold decrease of this inflammation marker was observed in the Meriva group. Finally, the subjects using Meriva were able to reduce their reliance on standard painkillers (NSAIDs, non-steroidal anti-inflammatory drugs) by 63 percent compared to patients on conventional medical therapy alone.
Taken together, these data show that Meriva turmeric extract improves the clinical benefit of a standard NSAIDs-based treatment of osteoarthritis, making it possible for patients to decrease their medication load and increase its efficacy.
Consistent with data from other human studies on various types of turmeric extracts, Meriva demonstrated a high degree of safety without producing any serious adverse side effects.
“This is great news for people who suffer from osteoarthritis and the physicians who treat them,” said Mark Blumenthal, Founder and Executive Director of the nonprofit American Botanical Council, an independent herbal medicine research and education organization in Austin, Texas.
“Turmeric has long been known to have anti-inflammatory and pain-relieving properties and this trial, on this special turmeric extract, is another important step towards validating the curcumin in turmeric as an increasingly popular herbal dietary supplement. When one considers the overall safety of turmeric extract and curcumin, especially compared to some of the pharmaceutical drugs which have had to be removed from the market due to serious safety concerns, the growing clinical evidence for the use of turmeric extract is compelling,” he added.
The authors of this trial write that “curcumin is one of the most extensively investigated products of natural origin. Its broad spectrum of bioactivity and low oral toxicity have expanded its use to several clinical conditions. Many potential beneficial properties of the natural product [i.e. curcumin] have not produced effective clinical results because curcumin shows a poor water solubility and stability, a low and unpredictable oral absorption, and a quick metabolism.”1 Researchers believe that these problems have hampered the clinical development of curcumin as a pharmaceutical product and as a dietary supplement. Meriva has exhibited high levels of oral bioavailability in a previous comparative animal pharmacokinetic* study.5The Meriva curcumin extact used in this clinical trial is a special patented combination of curcumin with soybean-derived phosphatidylcholine (1:2 ratio). P roduced and distributed by Indena SpA of Milan, Italy, the world’s largest manufacturer of standardized botanical extracts for the food, dietary supplement, pharmaceutical and cosmetic industries. Meriva has recently been introduced into the market as a dietary supplement ingredient marketed in the USA and Europe. In this clinical study, Meriva capsules prepared by Thorne Research Inc. (Dover, Idaho, USA) were used at a dosage of 1 gram Meriva curcumin complex per day (standardized to contain 18-22 percent curcuminoids, and corresponding to 200 mg curcumin per day).
Turmeric is a traditional spice, food and medicine, native to southeast Asia, and widely used in Ayurvedic system of traditional medicine in India. Turmeric is made from the roots and rhizomes (lateral roots) of the turmeric plant, a member of the same plant family as ginger. According to a recent review article, over 2,500 preclinical scientific investigations have supported the activity of curcumin from turmeric as a potential agent to treat directly or as an adjunct treatment for various chronic diseases such as inflammatory diseases, some forms of cancer and possibly also Alzheimer’s disease. Turmeric’s popularity has risen tremendously in the past few years as consumers learn more about its safety and wide spectrum of health benefits.2,3 Turmeric dietary supplements were ranked 5th in sales in natural food stores in 2009, up about 23 percent from the previous year, generating over $10 million in sales in that market channel alone, according to a report in the American Botanical Council’s journal HerbalGram, based on information fromSPINS, a market research firm which monitors sales of dietary supplements in the natural food channel of trade.6
* Pharmacokinetics is the study of the absorption, metabolism and excretion of specific nutritional or drug compounds in humans or animals.
1. Belcaro G, Cesarone MR, Dugall M, Pellegrini L, Ledda A, Grossi MG, Togni S, Appendino G. Product-evaluation registry of Meriva®, curcumin-phosphatidylcholine complex, for the complementary management of osteoarthritis.PanMinerva Med. 2010;52 (Suppl. 1 to No. 1):55-62.2. Aggarwal BB, Sung B. Pharmacological basis for the role of curcumin in chronic diseases: an age-old spice with modern targets. Trends Pharmacol Sci. 2009;30:85-94.
3. Engels G. Turmeric (Curcuma longa ). HerbalGram. 2010;86:1-3.
4. Anand P, Kunnumakkara AB, Newman RA, Aggarwal BB. Bioavailability of Curcumin: Problems and Promises. Mol Pharmaceutics. 2007;4(6):807-818.
5. Marczylo T, Verschoyle R, Cooke D, Morazzoni P, Steward W, Gescher A, Comparison of systemic availability of curcumin with that of curcumin formulated with phosphatidylcholine. Chemother Pharmacol.
Source : American Botanical Council
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