Chapter 2
Questions and answers about arthritis
What is arthritis?
Arthritis is a general term used to describe any disease or illness that causes inflammation of one or more joints. More than one hundred conditions are classified as arthritis by the medical profession. Some have names we recognize at once: rheumatoid arthritis, osteoarthritis and gout are examples. However, most forms of arthritis are relatively rare and receive limited public notice; these include carpal tunnel syndrome, ankylosing spondylosis, scleroderma, Lyme disease and systemic lupus.
What is a joint?
Joints are structures that occur where two bones meet. There are several types of joints: some allow movement while others do not. For example, joints linking bones in the arms and legs move, but those between the flat bones of the skull do not. Most joints contain a cartilage pad at the end of each bone, a fibrous capsule, a lining of synovial membrane, a space partially filled with fluid secreted by the membrane, and ligaments. Fibrous connective tissue links bones in immobile joints.
Mobile joints, also known as synovial joints, are found in the jaw, spine, arms, shoulders, hands, hips, legs and feet. They are characterized by a fibrous wall lined with a thin sac that secretes a lubricating substance known as synovial fluid. These joints also contain cartilage pads at the end of adjoining bones; these act as shock absorbers during physical activity.
What is osteoarthritis?
The rubbery tissue (cartilage) covering the ends of bones meeting inside synovial joints is damaged by osteoarthritis (OA), leading to pain during movement. Abnormal spurs of bone may grow inside the damaged joint and add to discomfort. Although the exact cause of OA is unclear, the following are important risk factors:
Joint injuries – caused by sports injuries or physical labour.
Gender – women are affected more often than men.
Age – people over 45 are at greatest risk.
Inherited conditions affecting the joints or cartilage. Excess body weight.
Any disease, or medication, that affects the normal production and function of joint cartilage.
It is most likely that OA will affect the fingers, spine and weight-bearing joints, including those in the hips, knees and feet. Swelling may occur, especially in the knee joints.
Osteoarthritis is the most common form of arthritis. It rarely develops before the age of 40 and almost everyone over the age of 75 is affected to some degree. It can be very mild, causing only an occasional twinge, or so severe that even the simplest activities become painful and difficult.
What is rheumatoid arthritis?
Rheumatoid arthritis (RA) is a chronic inflammatory disease that most commonly affects the synovial lining of joints; it can also cause inflammation of the lining surrounding the lungs and heart, and the membranes lining blood vessels. RA is caused by the body’s own immune system attacking normal tissue. If the attack continues untreated over a long period of time, the cartilage and bony parts of joints may be destroyed. Individual cases vary widely in severity, however.
About one per cent of the world’s population suffer from RA: every ethnic group is affected. Two to three times more women than men develop RA, and some experts believe hormones may be a factor because the risk decreases after the menopause. Genetics also plays a role in susceptibility to this condition and close relatives of people affected by RA are at risk of developing it. Siblings of RA patients have the highest risk of developing the disease.
Unlike other forms of arthritis, RA is symmetrical, attacking the same joints on both sides of the body. An attack can be extremely painful. Membranes surrounding a joint becomes inflamed, thickened, and produce an excessive amount of fluid. The build-up of this fluid produces pressure on the soft tissues surrounding the joint and damages the soft cartilage ‘cushions’ within the joint. The disease progresses at different rates, and its severity usually waxes and wanes over a number of years. RA will go into remission in a few people, usually within the first two years.
RA most commonly attacks the joints of the hands and feet, causing tenderness, swelling and pain. Generalized stiffness on getting out of bed in the morning is common. Usually late in the course of the disease, one in four RA patients develop hard rheumatoid nodules under their skin on the elbows, heels, hips, back of the head, fingers and toes.
What is gout?
Gout is a form of arthritis that occurs when crystals of uric acid accumulate in soft tissues, such as the kidneys and the joints of the feet and hands. The big toe is most frequently affected. Uric acid is a natural by-product of metabolism that is normally excreted in the urine. Gout occurs when the kidneys do not function adequately to remove uric acid from the body, or when the diet contains excessive quantities of foods containing substance called purines (proteins primarily found in the nucleus of cells). In both cases, the level of uric acid in the blood reaches abnormal concentrations and crystals of sodium biurate begin to form in soft tissues and joints. The crystal deposits grow for as long as the condition remains untreated.
Diet plays an important role in controlling this form of arthritis, and certain foods, including red meat, shellfish, anchovies, sardines, liver and sweetbreads should be avoided. The risk of an attack is increased by the excessive consumption of alcohol.
Gout tends to run in families, and men are more susceptible than women. Diabetes, high blood pressure and obesity are important risk factors.
What medications and treatments are used for the various forms of arthritis?
OSTEOARTHRITIS
The two most commonly prescribed treatments for OA are corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen and fenbufen. These work by blocking the action of specific hormone-like substances (prostaglandins), which are responsible for producing inflammation and, therefore, pain. Medications such as Tylenol and paracetamol relieve pain but do not reduce inflammation.
Recent scientific research demonstrates that glucosamine, a naturally occurring substance in the body, can reverse the damaging processes that destroy cartilage in the joints (see here).
RHEUMATOID ARTHRITIS
Anti-rheumatic drugs are designed to relieve pain and stiffness, maintain mobility and prevent deformation of joints affected by rheumatic disorders. Three types of anti-rheumatic drugs are available:
those that slow or halt the underlying condition causing the symptoms;
corticosteroids.
Drugs used to reduce symptoms are usually prescribed as a first line of treatment, and include aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) such as acemetacin, benorylate, diflunisal, fenbufen, fenoprofen, ibuprofen, mefenamic acid and tolmetin. They are called ‘non-steroidal’ to separate them from corticosteroid drugs, which also reduce inflammation. Although NSAIDs do nothing to stop the progress of the illness, they effectively reduce pain, swelling and stiffness that result from tissue inflammation. However, because the damage to joints remains, symptoms may recur.
If symptoms increase, drugs are prescribed which slow further damage to joints and tissues. These include:
gold-based drugs, such as auranofin;
immunosuppressants, such as azathioprine and chlorambucil;
chloroqine and hydroxychloroquine;
penicillamine (which is not an antibiotic);
sulphasalazine.
Corticosteroids control pain by blocking the biochemical processes that trigger inflammation. These drugs are used for short periods of time because they temporarily depress the immune system. All anti-rheumatic drugs should be used under medical supervision to control side effects, some of which can be distressing.
GOUT
Drugs used to prevent gout lower blood levels of uric acid. These include allopurinol, probenecid and sulphinpyrazone. Those prescribed to treat gout include NSAIDs and colchicine.
Which dietary supplements are helpful in treating arthritis?
FISH OIL
For decades, arthritis sufferers have experienced less pain and debilitating illness when they supplemented their diet with fish oil. No one knew why this was, and some medical experts doubted that the improvement was real and not simply a placebo effect. At the turn of this century, scientists at Cardiff University conducted a series of experiments exposing the cells responsible for the growth and repair of joint cartilage, called chondrocytes, to various mixtures of fatty acids. Not surprisingly, they found that adding omega-3 fatty acids (those found in oily fish and fish oil supplements) produced a dosedependent decrease in cellular activity linked with cartilage damage. While there is undoubtedly more to learn, it is now clear that stories about eating fish ‘to oil your joints’ are based on more than hearsay.
Fish oil is extracted from the flesh of oily fish such as herring, mackerel, salmon and trout. It is the best source of the omega-3 fatty acids needed to maintain healthy joints. These fatty acids have the added benefits of discouraging the formation of blood clots and helping to maintain normal blood pressure and cholesterol levels. They also are vital for healthy skin and hair.
Unlike cod liver oil, fish oil contains neither vitamin A nor D, and will not add to a build-up of these nutrients in the liver, which can be toxic in large amounts.
Take fish oil with food, as it may cause nausea when taken on an empty stomach. The usual recommended dose is 1000mg taken three times a day.
COD LIVER OIL
Cod liver oil has been associated with healthy bones and joint mobility since 1922, when it was discovered that a daily dose of cod liver oil prevented rickets, a crippling disease that causes bow legs in children. As the name states, this dietary supplement is derived specifically from the livers of cod fish. Scientists later found that its success in preventing rickets was specifically due to the amount of vitamin D in the oil. Cod liver oil differs from fish oil because it contains substantial amounts of both vitamins A and D, but lower levels of omega-3 fatty acids EPA and DHA (see Fish Oil). It is now recognized that the omega-3 fatty acids – which were unknown in 1922 – play an important role in maintaining healthy bones and joints.
A maximum of 3000mg per day is thought to be safe. Higher doses should not be used without a practitioner’s supervision because cod liver oil is rich in vitamin A, which can be toxic in large amounts.
GLUCOSAMINE SULFATE
Glucosamine sulfate is used in the body to build and repair joints, and maintain healthy ligaments, muscles and tendons. It has also been shown to act as an effective non-steroidal anti-inflammatory drug in the treatment of osteoarthritis.
In normal joints a balance exists between the processes that build, or synthesize, cartilage and those that break down or degrade it. In osteoarthritis the balance is tipped in favour of the processes that degrade cartilage. Other anti-inflammatory agents do not restore this balance, and research has shown they can actually add to the negative imbalance. Glucosamine, however, supports the biological processes responsible for synthesis, and so helps restore joint mobility.
Medical treatment for osteoarthritis aims to reduce or stop the degeneration of joint cartilage and control pain and other symptoms associated with this debilitating condition. According to European studies, glucosamine has about the same effect as the NSAID ibuprofen – a common treatment for this form of arthritis – but without the same degree of gastric side effects. Using both reductions in pain and increased movement as indicators, the value of this natural compound was found to be significant.
Some anti-inflammatory drugs reduce pain but inhibit the body’s ability to build new joint cartilage. Research strongly suggests that glucosamine actually supports the synthesis of cartilage, and may reduce the inhibition caused by NSAIDs.
The recommended dose is 500–1500mg per day, taken in 500mg doses up to three times a day. Take it with meals to avoid heartburn and indigestion. If you have a sensitive stomach take only one tablet per day. Usually it takes 4–6 weeks before the full effects of glucosamine are felt.
Glucosamine is generally thought to be non-toxic, and at the time this book was written there was no published scientific evidence that it interacted adversely with any medication. However, people sensitive to shellfish may experience mild stomach upset.
EVENING PRIMROSE OIL (EPO)
Seed oil from the evening primrose (no relation of the wild primrose) has been used as a food supplement for decades. It is an excellent source of GLA (gammalinoleic acid), an omega-6 fatty acid that some people fail to produce in adequate amounts, and one that has been shown to aid joint mobility, improve skin conditions, and reduce breast tenderness associated with PMS. Certain medications, viral infections, smoking, alcoholic beverages, ageing and excessive amounts of saturated dietary fat all slow the body’s production of this vital substance.
When self-supplementing, 3000mg per day is a safe maximum dose. This should be taken separately from fish oil. Note: starflower oil, extracted from the seeds of the borage plant, is frequently taken as a source of GLA. People with certain mental disorders, or those taking tranquillizers, should check with their doctors before using supplements containing GLA.
Which vitamins and minerals are important in preventing and treating arthritis?
CALCIUM
Calcium makes up about 1.5% of the body’s weight, and 99% of this is in bone. It is required for strong bones and teeth, and for normal biological activity in muscles, nerves and blood. Severe deficiency can produce rickets in children, and osteomalacia in adults. It is thought that the development of osteoporosis may be due to a mild deficiency of calcium over a number of years.
It is recommended that adults consume 800mg of calcium per day. The intake for adolescents, nursing mothers and pregnant women should be between 1.0 and 1.4g per day.
Good food sources of calcium include dairy products, canned fish, tofu, dried figs, dark green leafy vegetables and pulses (legumes).
VITAMIN D AND CALCIUM
Vitamin D and calcium are necessary to prevent bone loss and fractures associated with osteoporosis. For many years it was believed that a balanced diet and normal exposure to sunlight provided adequate levels of this important pair of nutrients, but scientists have reconsidered the matter. In the mid-1990s, calcium’s role in the prevention of osteoporosis was reviewed and the recommended daily intake for people over 65 was substantially increased from 800mg to 1500mg, or the equivalent of five 240ml/ 8fl oz glasses of milk. Most women in the United States, where the relevant studies took place, consume on average only 600mg each day.
Vitamin D helps the body absorb calcium and transport it to bones. Unfortunately, as we age our digestive systems are less able to absorb calcium; an additional boost of vitamin D helps correct this slow-down. Vitamin D is produced when a compound in the skin absorbs sunlight. As little as 15 minutes exposure per day is adequate to supply normal requirements of the nutrient. However, older people may tend to avoid the sun, and this compounds problems caused by their lowered capacity to absorb the nutrient. Reduced kidney and liver function make matters even worse.
For these reasons, supplements containing vitamin D and calcium are recommended. If you are over 65, or think your diet and sun exposure do not provided adequate levels of these nutrients, experts advise consuming 400 International Units (IU) a day. However, avoid taking excessive amounts of vitamins D. Prolonged intake of 600 micrograms or more a day may have toxic effects, including kidney damage and high blood pressure. Consult your doctor if you are taking digoxin, glycoside medication, or thiazide diuretics before using any supplement containing vitamin D.
Boron and vitamin K also work with calcium to maintain healthy bone structure. When you buy calcium supplements, check to see if these are included in the product.
VITAMIN E
There was a time when scientists did not believe that humans required vitamin E for good health. Recent research has shown, however, that this oily substance is a powerful antioxidant with anti-ageing properties. It is thought that vitamin E protects against cardiovascular disease by protecting the HDL cholesterol (sometimes called ‘good’ cholesterol) from damage by free radicals in the body. This reduces the build-up of atherosclerotic plaques on the walls of blood vessels.
There are other considerable benefits from vitamin E. When taken with vitamin C, vitamin E may also slow the effects of Alzheimer’s disease. Damaging free radicals are thought to play a significant role in the development of this debilitating illness, and an increasing number of scientific studies suggest antioxidant vitamins may prevent or slow its progress.
Experts believe it is safe to supplement the diet with 400 IU per day. However, prolonged use of large amounts of vitamin E (more than 1000 IU per day) may cause bleeding in people taking medication to thin the blood.
VITAMIN C
People with damaged or painful joints may have an increased need for vitamin C. Heavy smokers, athletes, heavy drinkers and people who are ill or recovering from illness or injury may also wish to supplement their diet with this nutrient.
Recent scientific studies have shown a link between diets rich in vitamin C and lower rates of cardiovascular disease and certain cancers. Vitamin C is also thought to enhance the immune system’s response to viral and bacterial infections, and help relieve cold symptoms by acting as a mild antihistamine.
Vitamin C is vital for the production of collagen, found in bone, tendons and skin. Also, in combination with vitamin E, vitamin C is a powerful antioxidant that helps fight any damaging build-up of oxidative free radicals in the body.
According to the National Institutes of Health (NIH), in the United States, a healthy adult should consume 200mg of vitamin C each day. Only a third of Americans achieve this, and one third consume less than 60mg per day. People eating processed foods as part of westernized diets fail to meet their body’s requirements for this crucial vitamin. Happily, the Eat to Beat Arthritis Diet provides plenty of fruits and vegetables rich in this vital nutrient.
Experts generally agree that, over the long term, 1500–2000mg of vitamin C a day is safe. Good food sources include red and green peppers, strawberries, kiwi fruit, and citrus fruit.
MAGNESIUM
Magnesium helps maintain healthy bone structure. In Great Britain, tea is a major source of this mineral. Other food sources include avocados, nuts, pulses (legumes) and wholegrains.
SELENIUM
Selenium is a mineral that acts as an anti-inflammatory in the body, and is therefore useful in controlling the symptoms of arthritis. Diets rich in selenium have been linked with lower rates of certain cancers and heart disease. Brazil nuts are the best food source of selenium, but it is also found in liver and other forms of offal, red meat, fish, and wheat grown in soil rich in this mineral. (Note: those suffering from gout should avoid liver and other offal.)
Selenium intake in Great Britain and most of the rest of Europe is very low – half the recommended daily allowance or less. In Finland, the general dietary intake of selenium dropped so low the government considered it a public health hazard, and fertilizers used to grow crops were supplemented with the mineral.
A safe long-term dose is 200 micrograms per day. Do not exceed 700 micrograms, as over time this and higher amounts can become toxic.
What other natural substances hold promise as treatments for arthritis?
CHONDROITIN SULPHATE
Chondroitin is a building substance in cartilage that was once thought to have as much therapeutic value as a dietary supplement as glucosamine. The two were combined in many commercial products. However, research has shown that chondroitin is poorly absorbed by the body, and its value as a supplement appears to be limited. Nutrimax, a company that makes a patented product containing both chondroitin and glucosamine, is funding research to assess its effectiveness.
MSM (METHYLSULFONYLMETHANE)
MSM is found in tiny quantities in every cell in the body. Although we know comparatively little about it, research suggests it is a necessary building block for a number of proteins, including those in muscles, connective tissue and joints.
As it appears to inhibit pain impulses and also act to control inflammation, MSM is one of the newer dietary supplements used to control arthritis. Early work suggests it may be especially useful for people suffering from osteoarthritis.
Testimonials suggest MSM reduces muscle spasms, increases blood flow, and may help repair cartilage. It has also been used to treat lupus and other auto-immune conditions, chronic back pain and to slow the growth of certain cancers.
Ronald M. Laurence, M.D., Ph.D., assistant clinical professor at UCLA School of Medicine, has written a book on this subject (The Miracle of MSM, Putnam, 1999). In an interview conducted by www.wholehealth.com, Dr Laurence was asked about the safety of this new supplement. He reportedly said: ‘In the thousands of patients I have treated who took 2000mg and more of MSM daily for months and years, I haven’t heard of any serious complaints to date.’ He continued, ‘In fact, I feel comfortable telling people that MSM is safer than water. Remember, though, MSM is a biologically active substance and can sometimes produce side effects, such as skin rash or minor gastrointestinal upset, in some people. If you’re on anticoagulants, you should check with your doctor before taking MSM, because it can occasionally have a blood-thinning effect.’
Dr Laurence recommends taking a combination of MSM and 500mg of glucosamine three times a day, and many patients experience less pain when they use this combination of supplements.
Take with food to minimize gastric upset.
BOSWELLIA
This herb is used as a treatment for arthritis in the traditional medicine of India. It is thought that boswellic acid blocks the action of leukotrines that stimulate an inflammatory response.
CAYENNE CREAM
A topical cream containing capsaicin, the substance in hot peppers that give them their sting, has been found useful in controlling the pain of arthritis. It appears to create a temporary diversion, and inhibits the production of a chemical substance that sends pain messages to the brain.
Use only as recommended on the product.
DMSO (DIMETHYL SULFOXIDE)
An industrial solvent approved by the United States Food and Drug Administration for a bladder disorder known as interstitial cystitis, DMSO was once widely used as an alternative treatment for several forms of arthritis. However, the highly unpleasant smell it caused in users lessened its appeal. It can also have toxic effects in some people. It is now used as a solvent in some products.
NIACINAMIDE
A double-blind study has shown that this form of vitamin B3 is an effective treatment for knee pain. Do not use this supplement without being monitored by your doctor, as high doses (about 3000mg per day) may have serious side effects.
SAME (S-ADENOSYLMETHIOINE)
It has been found that an anti-inflammatory effect similar to that of ibuprofen can be produced by SAMe (pronounced sammy), which is a form of the amino acid methionine. Compared with other non-prescription treatments, this supplement is expensive. It should not be taken by people with manic-depressive illness.
What are some of the alternative therapies used in the treatment of arthritis?
Acupressure – a massage technique in which the fingertips and thumbs apply pressure on specific points along the acupuncture meridians.
Alexander technique – a means of improving movement and posture by the effective and minimal use of muscles.
Aromatherapy – the use of aromatic essential oils to treat pain, inflammation and the underlying cause of many forms of ill-health.
Art therapy – by using art to express their feelings, patients gain relief from pain and the tensions that increase the sensation of pain.
Ayurvedic medicine – an ancient system of holistic healing originating in India. Remedies are based on diet, breathing exercises and yoga.
Bach flower remedies – the use of infusions of different plants to treat health-threatening emotional and physical imbalances.
Chiropractic – a system of manual manipulation of the spine used to relieve pain and illness throughout the body.
Colour therapy – use of colour to affect a person’s mental and physical state.
Feldenkrais – the system of yoga, stretching and exercise that improves one’s awareness of movement patterns and encourages the proper use of muscle groups.
Herbal medicine – holistic system of medicine based on the healing properties of plants.
Homoeopathy – a healing system based on the belief that minute amounts of substances that cause a symptom in a healthy person will cure that same symptom in one who is ill.
Hydrotherapy – therapy based on the use of different temperatures of water and compresses.
Meditation – a system of spiritual healing in which a person learns to focus their attention on a neutral object and relax.
Microwave therapy – deep heat treatment in which electrodes placed on a person’s skin pass electromagnetic waves to deeper parts of the body. The heat created increases blood flow to the area and relieves joint and muscle pain.
Nutritional therapy – the use of specific foods and food supplements to treat illness.
Occupational therapy – a system of care in which trained professionals devise ways for individuals to perform everyday tasks.
Osteopathy – a system of medical practice based on the theory that the loss of physical integrity, or form, causes illness. Treatment involves manipulation of the spine and joints, plus other therapeutic techniques.
Physiotherapy – a system of healing care in which a medical professional uses exercise to help restore movement and strength to the body.
Rolfing – a system of healing based on deep massage intended to realign the body’s structure by strengthening the body’s connective tissue, thus improving posture and balance.
Shiatsu – a system of treatment similar to acupressure, but here the therapist uses elbows, knees and feet as well as fingers and thumbs when applying pressure to the body’s meridian points.
Ultrasound – the use of sound waves to stimulate blood flow to an area of pain.
Yoga – a holistic system of therapy, originating in India, that utilizes breathing, exercises, meditation and relaxation to heal.
Zen – a system of spiritual care, based on Buddhist philosophies, that aims to integrate the mind, body and spirit in achieving a state of total fulfilment.