Treating Arthritis With Integrative Medicine
By Nancy Scanlan, DVM
For Veterinary Practice News
[Arthritis generally is treated using NSAIDs, especially the newer COX-2 inhibitors, and often with the addition of tramadol if pain control is incomplete.
But what can a practitioner do if liver and kidney function are compromised and tramadol is not enough? Glycosaminoglycans have become part of mainstream medicine, and the effectiveness of acupuncture is widely recognized. But these two treatments are just the beginning as far as other integrative methods are concerned.
In addition, some clients are mistrustful of any drug, no matter how widely used, but for them there are options as well.
Because complementary medicine acts in many different ways, rather than being various versions of the same basic action (as opposed to COX-2 inhibitors), practitioners often will find that using a number of different items works better than trying a single method.
The use of supplements that decrease cartilage degradation, reduce inflammation and help with muscle spasms—rather than just looking to decrease joint pain—often give the best long-term effects. Add physical therapy to increase flexibility and muscle strength, and the maximum benefit will be given.
Some studies of glucosamine and chondroitin in humans have cast doubt on their benefits for treating osteoarthritis pain.1 Part of the problem may be tied to the unreliability of some sources of glucosamine and the use of long-chain chondroitin that does not have the effects of a shorter molecule.2
Studies in dogs have shown its effectiveness for pain,3 though not all dogs respond this way. However, glycosaminoglycans have the ability to spare or even increase the thickness of joint cartilage in the presence of inflammation.4 So they are to be recommended, even if a client does not recognize improvement in the pet.
Be sure the client is using a brand that truly contains the amount of glucosamine stated on the label. Prolonged clotting time is a possible side effect, so discontinue use before surgery. MSM is often included with glucosamine products. A review of research articles reveals that MSM has helped arthritis pain in humans,5 and there may be an increased benefit when using it in combination with glucosamine and chondroitin.
Pain and inflammation are the two primary problems addressed by veterinarians treating arthritis. Acupuncture is invaluable for treating most cases of arthritis, though occasionally a few cases do not respond well. More often we see dogs that are initially carried into the office, and leave under their own power. The degree of response can vary from slight improvement to almost miraculous (when the immobile dog walks out).
Acupuncture may be performed by a human acupuncturist under a veterinarian’s supervision, but veterinarians certified in acupuncture are often preferable because they know more about drugs and animals.
D-phenylalanine inhibits the degradation of enkephlins6 and can prolong the effects of acupuncture7 and potentiate opiate analgesia.8 It is not commonly available as pure D-phenylalanine, so it must be purchased as the dl form (DLPA). The l-form alone helps with depression, but not with pain.
Willow bark (Salix alba) is common in a number of over-the-counter herbal preparations for pain. Willow bark contains salicylates and is similar to aspirin, both in its benefits and side effects. Clients must be cautioned not to mix willow bark with aspirin or prescription NSAIDs. It can be combined with DLPA, giving a result similar to combining other NSAIDs with tramadol.
Inflammation in a joint produces pro-inflammatory products, which result in pain, cartilage degradation and more inflammation in a degenerative cycle. Nitric oxide is produced within the synoviocytes and chondrocytes, giving rise to the free radical peroxynitrite. Tumor necrosis factor-alpha (TNF-alpha) and other cytokines also are involved in the formation of free radicals, partly by increasing the production of nitric oxide.9 Fish oil, a source of omega-3 fatty acids DHA and EPA, has anti-inflammatory effects and can help arthritis in dogs.10--11 The alpha linolenic acid in flax oil first must be converted to EPA, then DHA, and a human study found that the amounts of EPA and DHA in the body are greater when using fish oil instead of flax oil.12
Cats lack the enzyme to convert the alpha linolenic acid in flax to DHA and EPA, and so they can’t use flax oil at all. For vegans, algae oil is available, which has an equivalent action to fish oil, but only as DHA, not EPA, the preferred form for arthritis.13 Note that fish oil can prolong clotting time. While some pets love its fishy taste and will readily eat oil poured over their food, others hate it, so it must be given as capsules.
Other oils may be helpful as well. Borage oil and evening primrose oil block the formation of 2-series prostaglandins (PGs) and 4-series leukotrienes (LTs), which have proinflammatory effects. They have been found helpful to reduce pain and inflammation in arthritis in humans.14
A number of herbs and supplements have anti-inflammatory and analgesic properties. A combination of the proteolytic enzymes bromelain and trypsin has been shown to decrease arthritic pain.15 Antioxidants help quench inflammatory free radicals. Vitamins C and E have been used for this purpose16 as well as grape seed extract and pycnogenol.
Alpha tocopherol is the form of vitamin E most often studied, though gamma tocopherol has been suggested as a more effective form.17
Research results have varied, but this may be because of the wide range of doses used as well as the fact that when E acts as an anti-oxidant it turns into a pro-oxidant and needs vitamin C as a co-factor to return to its antioxidant form. Most studies use vitamin E alone.
The beneficial effects of herbs have been attributed to their anti-oxidant effects, although some other actions have been elucidated. Most research has used humans or mice as subjects, or has been conducted in vitro, but one research article shows the benefits of Boswellia (Boswellia frereana, or frankincense) for dogs.18 Boswellia suppresses the production of pro-inflammatory molecules.19
Yucca (Yucca schidigera) has anti-arthritic and anti-inflammatory action.20 There is a lot of interest in curcumin, the main curcuminoid in the spice turmeric (Curcuma longa). A review of clinical studies in humans using curcumin shows its promise in treatment of arthritis and other inflammatory diseases.21
Curcumin inhibits neutrophil activation, synoviocyte proliferation and angiogenesis. It also was found to strongly inhibit collagenase and stromelysin expression at micromolar concentrations.22
Red ginger (Zingiber officinale var. Rubra), has been shown to have anti-inflammatory properties and to suppress nitric oxide production.23 An Ayurvedan combination of Ashwaganda (Withania somnifera), Boswellia, ginger (Zingiber officinale) and turmeric was shown to be effective in a 32-week randomized placebo-controlled trial involving 90 patients.24 The Chinese herb Dong quai or Angelica (Angelica sinensis) inhibits nitric oxide and prostaglandin E(2) secretions in vitro.25 Corydalis (Corydalis spp.) has anti-inflammatory effects also.26 The most common side effects of these herbs are nausea and diarrhea.
Gui pi tan and Shu Jing HuoXue Tang are examples of Chinese formulas that contain a number of herbs shown to decrease pain and inflammation. Chai Hu Gui Zhi Tang helps with muscle spasms.
Often so much attention is focused on radiographic joint changes that we forget that muscle spasms and soreness are a big part of the problem. When an animal is less active, muscle wasting occurs, making it even more difficult to rise from a prone position.
Massage therapy, trigger-point therapy, heat and underwater treadmill use are helpful for these problems, improving strength and flexibility in the patient.
Human massage therapists are not necessarily aware of the fragility of our patients, especially the smaller ones, and so the best results are generally found with those who have undergone training in one of the physical therapy certification courses.
Nancy Scanlan practices at Shasta Lake Veterinary Clinic in Shasta Lake, Calif. She is immediate past president of the American Holistic Veterinary Medical Assn., president of the Veterinary Botanical Medical Assn., and president and founder of the California Veterinary Holistic Medical Assn. Her book, “Complementary Medicine for Veterinary Technicians and Nurses” (Wiley-Blackwell), is due out in January.
1. Clegg DO et al, Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006 Feb 23;354(8):795-808.
2. Deal CL, Moskowitz RW. Nutraceuticals as therapeutic agents in osteoarthritis. The role of glucosamine, chondroitin sulfate, and collagen hydrolysate. Rheum Dis Clin North Am. 1999 May;25(2):379-95.
3. McCarthy G, et al. Randomised double-blind, positive-controlled trial to assess the efficacy of glucosamine/chondroitin sulfate for the treatment of dogs with osteoarthritis. Vet J. 2007 Jul;174(1):54-61. Epub 2006 May 2.
4. Naito K, et al. Evaluation of the effect of glucosamine on an experimental rat osteoarthritis model. Life Sci. 2010 Mar 27;86(13-14):538-43. Epub 2010 Feb 24.
5. Brien S, et al. Systematic review of the nutritional supplements dimethyl sulfoxide (DMSO) and methylsulfonylmethane (MSM) in the treatment of osteoarthritis. Osteoarthritis Cartilage. 2008 Nov;16(11):1277-88. Epub 2008 Apr 15.
6. Walsh NE, et al. Analgesic effectiveness of D-phenylalanine in chronic pain patients. Arch Phys Med Rehabil. 1986 Jul;67(7):436-9.
7. Kitade T, et al. Studies on the enhanced effect of acupuncture analgesia and acupuncture anesthesia by D-phenylalanine (2nd report)--schedule of administration and clinical effects in low back pain and tooth extraction. Acupunct Electrother Res. 1990;15(2):121-35.
8. Russell AL, McCarty MF. DL-phenylalanine markedly potentiates opiate analgesia - an example of nutrient/pharmaceutical up-regulation of the endogenous analgesia system. Med Hypotheses. 2000 Oct;55(4):283-8.
9. Cuzzocrea S.
Role of nitric oxide and reactive oxygen species in arthritis.
Curr Pharm Des. 2006;12(27):3551-70.
10. Hansen RA, et al. Fish oil decreases matrix metalloproteinases in knee synovia of dogs with inflammatory joint disease. J Nutr Biochem. 2008 Feb;19(2):101-8. Epub 2007 May 24.
11. Calder PC. Dietary modification of inflammation with lipids. Proc Nutr Soc. 2002 Aug;61(3):345-58.
12. Wilkinsona, Paul et al. Influence of α-linolenic acid and fish-oil on markers of cardiovascular risk in subjects with an atherogenic lipoprotein phenotype. Atherosclerosis. 2005 July; 181(1):115-124
13. Doughman SD. Omega-3 fatty acids for nutrition and medicine: considering microalgae oil as a vegetarian source of EPA and DHA. Curr Diabetes Rev. 2007 Aug;3(3):198-203.
14. Belch JJ, Hill A. Evening primrose oil and borage oil in rheumatologic conditions. Am J Clin Nutr. 2000 Jan;71(1 Suppl):352S-6S.
15. Klein G, et al. Efficacy and tolerance of an oral enzyme combination in painful osteoarthritis of the hip. A double-blind, randomised study comparing oral enzymes with non-steroidal anti-inflammatory drugs. Clin Exp Rheumatol. 2006 Jan-Feb;24(1):25-30.
16. Darlington LG, Stone TW. Antioxidants and fatty acids in the amelioration of rheumatoid arthritis and related disorders. Br J Nutr. 2001 Mar;85(3):251-69.
17. Jiang Q, et al. A combination of aspirin and gamma-tocopherol is superior to that of aspirin and alpha-tocopherol in anti-inflammatory action and attenuation of aspirin-induced adverse effects. J Nutr Biochem. 2009 Nov;20(11):894-900. Epub 2008 Nov 6.
18. Reichling J, et al. Dietary support with Boswellia resin in canine inflammatory joint and spinal disease. Schweiz Arch Tierheilkd. 2004 Feb;146(2):71-9.
19. Blain EJ, et al. Boswellia frereana (frankincense) suppresses cytokine-induced matrix metalloproteinase expression and production of pro-inflammatory molecules in articular cartilage. Phytother Res. 2010 Jun;24(6):905-12.
20. Cheeke PR, et al. Anti-inflammatory and anti-arthritic effects of Yucca schidigera: a review. J Inflamm (Lond). 2006 Mar 29;3:6.
21. Hsu CH, Cheng AL. Clinical studies with curcumin. Adv Exp Med Biol. 2007;595:471-80.
22. Jackson JK, et al. The antioxidants curcumin and quercetin inhibit inflammatory processes associated with arthritis. Inflamm Res. 2006 Apr;55(4):168-75.
23. Shimoda H, et al. Anti-inflammatory properties of red ginger (Zingiber officinale var. Rubra) extract and suppression of nitric oxide production by its constituents. J Med Food. 2010 Feb;13(1):156-62.
24. Chopra A, et al. A 32-week randomized, placebo-controlled clinical evaluation of RA-11, an Ayurvedic drug, on osteoarthritis of the knees. J Clin Rheumatol. 2004 Oct;10(5):236-45.
25. Chao WW, et al. Inhibitory effects of Angelica sinensis ethyl acetate extract and major compounds on NF-kappaB trans-activation activity and LPS-induced inflammation. J Ethnopharmacol. 2010 May 27;129(2):244-9. Epub 2010 Apr 3.
26. Kubo M, et al. Anti-inflammatory activities of methanolic extract and alkaloidal components from Corydalis tuber. Biol Pharm Bull. 1994 Feb;17(2):262-5.
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