Bone and joint health

DEFINITION: A wide range of both traditional and complementary and alternative methods are used to prevent or treat disorders of the joints, which consist primarily of bones covered by cartilage that reduces friction, by tendons for stability, and by synovial membranes for lubrication.

Overview

Many diseases and conditions affect the bones and joints. “Arthritis” is the general term for joint inflammation and is the primary distinguishing feature of joint disorders. Complementary and alternative medicine (CAM) seeks to reduce inflammation regardless of the cause of arthritis. Osteoarthritis, also known as degenerative joint disease, is the most common disorder involving joint movement. Not limited to old age, osteoarthritis can result from a complex interaction of mechanical, biological, or genetic factors that result in the depletion of joint cartilage. Rheumatoid arthritis is an autoimmune disease in which the immune system attacks the tissues surrounding and cushioning the joint, eventually affecting the cartilage and bones of the joints. Gout and bursitis also affect the joint.

Some diseases affecting the joint also affect other tissues and organs. These diseases include systemic lupus erythematosus, fibromyalgia, and ankylosing spondylitis. Another disorder, osteoporosis, is the decrease in density of many different bones of the body and does not affect the joint. Osteoporosis is often confused with osteoarthritis, yet they are very different medical conditions with little in common.

Osteoarthritis

Osteoarthritis (OA) is distinguished by degeneration of joint cartilage and adjacent bone, leading to pain, difficulty in movement, and stiffness. OA can affect any joints in the body, including knees, hips, shoulders, vertebrae, fingers, toes, and the temporomandibular joint, which is in the jaw. Standard treatments consist of exercise or physical therapy programs, analgesic drugs or corticosteroids for pain, and, as a last resort, joint replacement surgery.

None of the standard treatments regenerate lost or damaged cartilage. Cartilage is composed of collagen and proteoglycan. Collagen is a large fibrous protein, whereas proteoglycan consists of a core protein with linkages to many long-chain carbohydrates known as glycosaminoglycans. Chondroitin sulfate is the glycosaminoglycan found in collagen. Because chondroitin sulfate is an integral part of collagen, and glucosamine is an essential metabolic intermediate in the formation of collagen, it was reasoned that providing these compounds to persons with joint disorders would serve as a stimulus for the formation of collagen.

Considerable research has been reported on the effectiveness of glucosamine and chondroitin sulfate in halting and reversing joint degeneration. Although early research did indeed seem to show effectiveness, there were some questions about research design and methodology. Later studies were more rigorous in nature, involving larger numbers of persons and using the gold standard of clinical trials: randomized, double-blind, and placebo-controlled trials. Meta-analyses compile the data from many studies for overall statistical analyses. In the case of glucosamine and chondroitin, recent analyses do not support much benefit from their use.

A review article in 1998 reported on studies that evaluated the effectiveness of glucosamine and chondroitin sulfate in reducing pain symptoms in OA. Most studies showed that persons receiving glucosamine had a reduction in pain score, compared with those receiving placebo. Fewer studies were reported on the effectiveness of chondroitin sulfate, but the compound appeared to produce what were called favorable outcomes. An analysis reported in 2003 found that glucosamine was significant in alleviating pain and in maintaining cartilage, while chondroitin was effective in some indices of pain reduction.

Another review in 2008 studied the results of twenty-five randomized controlled studies involving 4,963 persons. When all studies (including older studies) were analyzed, glucosamine improved pain more than did a placebo after six months. When the analysis was restricted to higher-quality studies with adequate blinding (in which neither the persons studied nor the researchers knew the identity of the treatments), no benefit was observed.

A meta-analysis was reported in 2007 on twenty trials evaluating the effectiveness of chondroitin sulfate for reducing symptoms of OA. Heterogeneity among the trials made analysis difficult, but when only large, methodologically sound trials were included in the analysis, no significant benefits of chondroitin were found.

A two-year study reported in 2006 evaluated the effectiveness of glucosamine and chondroitin sulfate on slowing structural damage of knee OA. Measurements of joint space width (cartilage depletion) were used as measures of structural damage. At the two-year stage of treatment, no statistical differences were found among the treatments, compared with the placebo control. The combination of glucosamine and chondroitin may be less active, compared with their individual effects. Persons with less severe OA at the beginning of the study tended to show less joint loss than those using a placebo.

A large glucosamine/chondroitin arthritis intervention trial (GAIT) involved 1,583 persons. After twenty-four weeks of treatment, glucosamine or chondroitin singly or in combination did not show the significant 20 percent reductions in knee pain, compared with placebo, although the groups did show numerical improvements over placebo. A subgroup of persons with moderate to severe pain at the beginning of the study showed a significant reduction in pain, compared with placebo.

A companion GAIT trial studied the effect of glucosamine and chondroitin singly or in combination on progressive loss of joint space width (JSW). At two years, no treatment achieved statistically significant differences in JSW loss, compared with placebo, although the placebo had less JSW loss than anticipated.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disorder in which the immune system attacks the tissues lining the joints, causing swelling, pain, and stiffness. Rheumatoid arthritis can eventually affect the bones and cartilage in the joints.

CAM seeks to alleviate the symptoms of rheumatoid arthritis without attempting cures for the underlying causes. Mind/body techniques, such as relaxation, imagery, and biofeedback, can improve symptoms such as pain, psychological state, physical function, and ability to cope. In terms of dietary supplements, some clinical studies have shown that omega-3 fatty acids may be beneficial in reducing the inflammation of rheumatoid arthritis. Other evidence suggested that gamma linolenic acid can have the same effect.

Tai Chi is a traditional martial art that combines slow and gentle movements with mental focus. A twelve-week study showed that Tai Chi improved muscle function in lower limbs in persons with RA. Persons using Tai Chi experienced improved psychosocial benefits such as less pain and improved posture, balance, and coordination.

Other Joint Diseases and Conditions

Gout is a recurrent, acute inflammation of peripheral joints, such as the big toe, instep, ankle, knee, wrist, and elbow. The condition is caused by deposits of monosodium urate crystals in cartilage, tendons, and ligaments and can become chronic with joint deformities. CAM focuses on the diet and includes recommendations such as avoiding foods with high purine content (such as beef, organ meats, sardines, and anchovies), eating cherries, taking fish oil supplements, minimizing alcohol consumption, and drinking eight glasses of water per day.

Systemic lupus erythematosus (SLE) is an autoimmune disease in which antibodies attack connective tissue cells. Connective tissue serves to support and connect organs, muscles, joints, and other body parts. Because connective tissue is widespread, the organs affected and symptoms observed are also broad. The vast majority of persons with SLE experience joint pain and swelling.

A few studies have indicated that dehydroepiandiosterone (DHEA) may lead to decreased symptoms of lupus. Persons with lupus have abnormally high levels of estrogen metabolites and low levels of testosterone. DHEA may control these hormone abnormalities and may have effects on immune system components, such as a decrease in pro-inflammatory cytokines. Preliminary studies have also indicated a beneficial effect of omega-3 fatty acids in fish oils on reducing abnormal levels of the immune components cytokine and interleukin.

Fibromyalgia (FM), or fibromyalgia syndrome, is a disorder characterized by chronic pain, tenderness, and stiffness in soft tissues, including muscles, tendons, and ligaments. FM most commonly affects women, and its cause is unknown. Some believe the disorder is triggered by physical or mental stress. Other symptoms of the disorder include severe fatigue, nonrestorative sleep, irritable bowel syndrome, depression, and cognitive difficulty (also called brain fog).

CAM seems to be particularly useful in treating FM because conventional therapies, namely drugs, are only partially effective and may have undesirable side effects. The treatments focus on the overall health of the person with FM, including his or her emotional state and nutritional health, and how these states can affect the condition. A review article found the largest improvements occurred with mind/body techniques, such as biofeedback, hypnosis, and cognitive behavioral therapy, especially when they were part of a multidisciplinary approach to treatment. Acupuncture was only moderately effective, while manipulative techniques such as chiropractic and massage were least effective. Another study, however, showed that just twenty minutes of moderate-pressure massage can lessen the flow of chemicals associated with pain and stress while increasing production of serotonin, a nerve transmitter that improves mood.

Osteoporosis

Osteoporosis (OP), or “porous bone,” is the gradual weakening of bone structure caused by the depletion of calcium and other minerals. The condition can lead to bone fractures. Fractures are most common in the arm bone, vertebrae, and hip. Women are more subject to OP than men, but before menopause, estrogen secretion provides a protective effect against OP. For both prevention and treatment of OP, emphasis is placed on consuming adequate calcium and vitamin D and engaging in weight-bearing exercises. Prevention is more successful than treatment.

Estrogen therapy was common practice for postmenopausal women because of the beneficial effects in preventing hot flashes and reducing OP. However, a large Women’s Health Initiative Study concluded that the health risks of estrogen therapy exceeded its benefits. In the search for alternatives to estrogen therapy, attention has focused on the use of dietary isoflavones. Isoflavones are non-nutritive compounds found in relatively large amounts in soybeans. The most common isoflavones are genistein and daidzein. They are also known as phytoestrogens, because they are similar in structure to estrogens and have weak estrogenic activity. Researchers have shown that isoflavones bind to estrogen receptors in osteoblast (bone-forming) cells, although in a manner different from estrogen. As a result, isoflavones were characterized as selective estrogen receptor modulators that could provide some of the beneficial effects of estrogen without the negative effects. Isoflavones could also inhibit osteoclast (bone-breakdown) cells by decreasing acid secretion or regulatory enzyme activities.

A review article summarized the results of two double-blind, randomized-control studies and one case-control study. Those persons receiving isoflavone treatments showed improvements in bone mass and reductions in the loss of bone mass, compared with those persons in the control group.

Another study evaluated the effect of isoflavones on bone resorption. Subjects were provided with radioactive calcium and three levels of isoflavones in a double-blind, randomized-control study. Serum and urinary samples were taken and analyzed for radioactive calcium to determine the rate of bone resorption (loss). Isoflavones did not have any influence on bone resorption.

Another study compared the effect of isoflavones on bone mineral density (BMD) in men and women. The results showed that isoflavones had a modest benefit in preserving spine but not hip BMD in women.

Bibliography

Baig, Sara and Dana DiRenzo. "Complementary and Alternative Medicine Use in Rheumatoid Arthritis." Current Rheumatology Reports, vol. 22, no. 61, 26 Aug. 2020, doi.org/10.1007/s11926-020-00938-z. Accessed 12 Dec. 2022.

Beers, Mark H., ed. The Merck Manual of Medical Information, Second Home Edition. Whitehouse Station, N.J.: Merck Research Laboratories, 2003.

Bordes, Jude des, et. al. "Knowledge, Beliefs, and Concerns about Bone Health from a Systematic Review and Metasynthesis of Qualitative Studies." Plos One, 15 Jan. 2020, doi.org/10.1371/journal.pone.0227765. Accessed 12 Dec. 2022.

Brynin, Rona. “Soy and Its Isoflavones: A Review of Their Effects on Bone Density.” Alternative Medicine Review 7, no. 4 (2002): 317-326.

Clegg, Daniel, et al. “Glucosamine, Chondroitin Sulfate, and the Two in Combination for Painful Knee Osteoarthritis.” New England Journal of Medicine 354 (February 23, 2006): 795-808.

Kelly, Gregory. “The Role of Glucosamine Sulfate and Chondroitin Sulfates in the Treatment of Degenerative Joint Disease.” Alternative Medicine Review 3, no. 1 (1998): 27-39.

Reichenbach, Stephan, et al. “Meta-analysis: Chondroitin for Osteoarthritis of the Knee or Hip.” Annals of Internal Medicine 146 (2007): 580-590.

“Rheumatoid Arthritis: In Depth.” National Center for Complementary and Integrative Health, January 2019, www.nccih.nih.gov/health/rheumatoid-arthritis-in-depth. Accessed 17 July 2024.

Sawitzke, Allen, et al. “ The Effect of Glucosamine and/or Chondroitin Sulfate on the Progression of Knee Osteoarthritis.” Arthritis and Rheumatism 58, no. 10 (2008): 3183-3191.

"Treatments for Osteoarthritis." Arthritis Foundation, www.arthritis.org/health-wellness/treatment/treatment-plan/disease-management/treatments-for-osteoarthritis. Accessed 17 July 2024.