Joint Pain Protocol: A Resource For Practitioners


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by Fullscript’s Integrative Medical Advisory Team

Joint pain is just one of the clinical symptoms of osteoarthritis, a condition that affects over 27 million people in the United States. Osteoarthritis is also a leading cause of physical disability in elderly individuals worldwide. (21) The number of individuals with osteoarthritis and the resulting strain on the healthcare system is only expected to increase with the growing aging population and the prevalence of obesity. (1)

While there is no cure for osteoarthritis, treatment aims to minimize symptoms and typically includes lifestyle modification and use of analgesics. (1) This article provides an overview of osteoarthritis, including its causes, risk factors, signs, and symptoms, as well as an integrative treatment protocol using dietary supplements.

What is osteoarthritis?

Osteoarthritis (OA), the most common form of arthritis, is a progressive joint disease. OA is characterized by subchondral bone sclerosis, cartilage matrix degradation, and osteophyte formation. (24) The pathogenesis of the disease occurs through multiple pathways that result in inflammation, biological aging of chondrocytes, and the loss of structural components, including type II collagen and glycosaminoglycans (e.g., chondroitin sulfate and hyaluronic acid). (15) The disease is often assessed using the WOMAC (Western Ontario and McMaster Universities) knee osteoarthritis index, a symptom questionnaire examining stiffness, joint pain, and limitation of physical function. The Lequesne index is also commonly used to assess knee pain, function limitation, and maximum distance walked. (10)

Causes and risk factors

Several causes and risk factors have been identified in the development of OA, including:

  • Aging
  • Genetic predisposition
  • Obesity
  • Inflammation
  • Excessive mechanical loading (24)
  • Trauma
  • Being female (15)
Physiotherapy treatment in a brightly lit room.

Osteoarthritis treatment aims to reduce symptoms such as joint pain, swelling, and stiffness.

Signs, symptoms, and complications

Structural changes in OA can lead to several symptoms and may eventually progress to physical disability. Symptoms are commonly present in the knees, hips, hands, and spine. (15)

The signs and symptoms associated with OA include:

  • Joint pain and stiffness
  • Swelling
  • Tenderness (24)
  • Crepitation (cracking) on motion
  • Limited joint mobility (16)

Integrative protocol for joint pain

Pharmaceutical treatment of OA includes non-steroidal anti-inflammatory drugs (NSAIDs), analgesics, and corticosteroids. Long-term use of these medications may result in severe side effects, which often prompts patients to explore complementary treatments. (1)(14) The dietary supplements in this integrative protocol have been shown to effectively reduce symptoms of OA.

Glucosamine

Glucosamine is a water-soluble amino monosaccharide that is produced naturally in the body and is present in high quantities in articular cartilage. (24) The compound is a building block of glycosaminoglycans present in the cartilage matrix and synovial fluid, which reduces friction between cartilage in synovial joints. As a dietary supplement, it has been suggested that glucosamine is partially absorbed in the intestine and targets the joints, where it exerts protective actions, such as improving mobility and pain. (22)(24) Glucosamine is commonly recommended in combination with chondroitin, as research shows the combination may improve effectiveness. (7)

Research findings:

  • Individual Randomized Double-Blind Placebo-Controlled (RDBPC) studies consistently demonstrate a reduction in pain and global symptoms of OA (12)
  • However, reviews and meta-analyses do not confirm this finding (22)
  • Combination with chondroitin may increase overall effectiveness (7)

US: Search for Glucosamine in the Fullscript catalog.
CAN: Search for Glucosamine in the Fullscript catalog.

Turmeric powder and fresh turmeric on wooden background.

Meriva® is a proprietary curcumin complex that has been shown to reduce pain in individuals with osteoarthritis.

Turmeric (Curcuma longa)

Curcumin is an anti-inflammatory pigment and primary active constituent of turmeric. It has been shown to have over 100 molecular targets, the most significant being pro-inflammatory enzymes, as well as inflammatory transcription factors and their genomic expression. (1)(3) One formulation of curcumin known as Meriva® is a proprietary curcumin-phosphatidylcholine phytosome complex. Research has demonstrated that Meriva® may be used to improve the quality of life and decrease the use of NSAIDs in patients with osteoarthritis. (1) Meriva® is generally safe and tolerability has been shown to be comparable to ibuprofen and acetaminophen. (3)(5)

Research findings:

  • In small clinical trials (< 100 subjects), demonstrated an effect in pain reduction, comparable to ibuprofen (5)
  • One recent review confirmed that both whole turmeric extract and curcumin demonstrated a short-term reduction in pain (3)

US: Search for Curcumin or MERIVA in the Fullscript catalog.
CAN: Search for Curcumin or MERIVA in the Fullscript catalog.

Collagen

Collagen is a structural protein found in connective tissues and fibrous tissues of the body, including bone, cartilage, tendons, ligaments, intervertebral discs, skin, and hair. There are approximately 28 different types of collagen, but five of the most common types include type I (dermis, tendons, ligaments, bone), type II (cartilage, vitreous body, nucleus pulposus), type III (skin, vessel wall, reticular fibres), type IV (basal lamina, epithelial layer of basement membranes), and type V (lung, cornea, hair, fetal membranes, bones). (18) As a dietary supplement, hydrolyzed collagen is produced from various sources, which include natural eggshell membrane (NEM®), providing collagen type I, (14) chicken cartilage, providing collagen type II, bovine collagen, providing collagen type I and III, (15) and marine-sourced collagen, providing collagen type I. (19) Certain collagen supplements may also contain naturally-occurring chondroitin sulfate and hyaluronic acid, making their composition similar to that of human articular cartilage. (14) Research suggests that hydrolyzed collagen is used as a substrate to build the collagen fibrillar network, which may explain its beneficial effects on the symptoms of OA. (15)

Research findings:

  • A reduction in WOMAC index, stiffness score, and VAS score was shown (4)(15)
  • Type 1 collagen contained in Eggshell Membrane has shown to improve pain and stiffness (14)

US: Search for Collagen in the Fullscript catalog.
CAN: Search for Collagen in the Fullscript catalog.

Frankincense in a small wooden bowl.

The gum resin in Boswellia serrata has been researched for its anti-inflammatory, analgesic, and anti-arthritic effects.

Boswellia serrata

Boswellia serrata, also known as Indian frankincense, is an ancient herb with anti-arthritic, analgesic, and anti-inflammatory effects. 3-O-acetyl-11-keto-beta-boswellic acid (AKBA), considered to be its most bioactive component, is found in the gum resin extract of the plant. AKBA has been shown to inhibit the enzyme 5-lipoxygenase (5-LOX), which is involved in synthesizing leukotrienes, metabolites of arachidonic acid, in the inflammatory cascade. (16) Two proprietary formulations, Aflapin® and 5-Loxin®, are standardized to contain 20% and 30% AKBA, respectively. (17)(21) 5-Loxin® has been shown to inhibit tumor necrosis factor-α and interleukin-1β, which are pro-inflammatory cytokines. Aflapin® may inhibit the enzyme MMP-3 involved in cartilage degradation. Research has demonstrated that these Boswellia extracts are safe for long-term use in humans. (17)

Research findings:

  • 5-Loxin® has shown to improve pain and physical function scores in addition to a reduction in synovial fluid matrix metalloproteinase-3 (16)(17)(21)
  • Constituents of Boswellia like AKBA have shown benefits as early as 5 days of treatment (21)

US: Search for Boswellia serrata in the Fullscript catalog.
CAN: Search for Boswellia serrata in the Fullscript catalog.

Chondroitin sulfate

In the body, chondroitin sulfate (CS) provides structure, resistance, and elasticity to cartilage tissue. (23) CS consists of glycosaminoglycans and is attached to proteins, forming part of the aggrecan of cartilage. (20) CS supplements are manufactured from animal sources including bovine and shark cartilage. (8) Clinical studies have demonstrated that CS supplementation may slow the progression of OA, increase joint function, and reduce pain. (23) Several mechanisms responsible for the benefits of CS have been proposed, including suppressing inflammatory mediators, stimulating the production of the extracellular cartilage matrix, and inhibiting the degradation of cartilage. (20)

Research findings:

  • Chondroitin sulfate has shown to increase total cartilage volume (11)
  • Functional magnetic resonance imaging (fMRI) of patella and leg pain was shown to be decreased under chondroitin sulfate treatment in the region of the mesencephalic periaqueductal gray region (9)

US: Search for Chondroitin sulfate in the Fullscript catalog.
CAN: Search for Chondroitin sulfate in the Fullscript catalog.

Older couple riding bicycles in a park.

Dietary supplements can help to minimize osteoarthritis symptoms and improve the quality of life in patients.

Additional interventions

Several nutrients and botanicals, including glucosamine, turmeric, collagen, Boswellia serrata, and chondroitin sulfate, have been shown to reduce osteoarthritis symptoms in clinical trials.

There is also promising preliminary evidence demonstrating a reduction in OA symptoms with green-lipped mussel extract, (2) L-carnitine, (6) and pycnogenol. (13) Further clinical trials are needed to demonstrate effective doses and safety. A protocol using natural supplements can be used therapeutically on its own or as an adjunct to existing treatment. If you are not an integrative healthcare provider, we recommend speaking with one to find out whether these supplements are right for your wellness plan.

If you are a practitioner, consider signing up to Fullscript. If you are a patient, talk to your healthcare practitioner about Fullscript!

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Disclaimer

The Fullscript Integrative Medical Advisory team has developed or collected these protocols from practitioners and supplier partners to help health care practitioners make decisions when building treatment plans. By adding this protocol to your Fullscript template library, you understand and accept that the recommendations in the protocol are for initial guidance and may not be appropriate for every patient.

  1. Belcaro, G., Cesarone, M. R., Dugall, M., Pellegrini, L., Ledda, A., Grossi, M. G., … Appendino, G. (2010). Efficacy and safety of Meriva®, a curcumin-phosphatidylcholine complex, during extended administration in osteoarthritis patients. Alternative medicine review, 15(4), 337-44.
  2. Coulson, S., Vecchio, P., Gramotnev, H., & Vitetta, L. (2012). Green-lipped mussel (Perna canaliculus) extract efficacy in knee osteoarthritis and improvement in gastrointestinal dysfunction: A pilot study. Inflammopharmacology, 20(2), 71-76.
  3. Di Pierro, F., Rapacioli, G., Di Maio, E. A., Appendino, G., Franceschi, F., & Togni, S. (2013). Comparative evaluation of the pain-relieving properties of a lecithinized formulation of curcumin (Meriva(®)), nimesulide, and acetaminophen. Journal of pain research, 6, 201–205.
  4. García-Coronado, J. M., Martínez-Olvera, L., Elizondo-Omaña, R. E., Acosta-Olivo, C. A., Vilchez-Cavazos, F., Simental-Mendía, L. E., & Simental-Mendía, M. (2018). Effect of collagen supplementation on osteoarthritis symptoms: A meta-analysis of randomized placebo-controlled trials. International Orthopaedics, 43(3), 531-538.
  5. Kuptniratsaikul, V., Thanakhumtorn, S., Chinswangwatanakul, P., Wattanamongkonsil, L., & Thamlikitkul, V. (2009). Efficacy and safety of Curcuma domestica extracts in patients with knee osteoarthritis. The Journal of Alternative and Complementary Medicine, 15(8), 891-897.
  6. Mahdavi, A. M., Mahdavi, R., Kolahi, S., Zemestani, M., & Vatankhah, A. (2015). L-Carnitine supplementation improved clinical status without changing oxidative stress and lipid profile in women with knee osteoarthritis. Nutrition Research, 35(8), 707-715.
  7. McAlindon, T. E., Lavalley, M. P., Gulin, J. P., & Felson, D. T. (2000). Glucosamine and chondroitin for treatment of osteoarthritis: A systematic quality assessment and meta-analysis. JAMA, 283(11), 1469.
  8. MedlinePlus. (2018, June 08). Chondroitin sulfate. Retrieved from https://medlineplus.gov/druginfo/natural/744.html
  9. Monfort, J., Pujol, J., Contreras-Rodríguez, O., Llorente-Onaindia, J., López-Solà, M., Blanco-Hinojo, L., . . . Benito, P. (2017). Effects of chondroitin sulfate on brain response to painful stimulation in knee osteoarthritis patients. A randomized, double-blind, placebo-controlled functional magnetic resonance imaging study. Medicina Clínica, 148(12), 539-547.
  10. Pavelká, K., Gatterová, J., Olejarová, M., Machacek, S., Giacovelli, G., & Rovati, L. C. (2002). Glucosamine sulfate use and delay of progression of knee osteoarthritis. Archives of Internal Medicine, 162(18), 2113.
  11. Railhac, J., Zaim, M., Saurel, A., Vial, J., & Fournie, B. (2012). Effect of 12 months treatment with chondroitin sulfate on cartilage volume in knee osteoarthritis patients: A randomized, double-blind, placebo-controlled pilot study using MRI. Clinical Rheumatology, 31(9), 1347-1357.
  12. Richy, F., Bruyere, O., Ethgen, O., Cucherat, M., Henrotin, Y., & Reginster, J. (2003). Structural and symptomatic efficacy of glucosamine and chondroitin in knee osteoarthritis. Archives of Internal Medicine, 163(13), 1514.
  13. Rohdewald P. J. (2018). Review on sustained relief of osteoarthritis symptoms with a proprietary extract from pine bark, pycnogenol. Journal of medicinal food, 21(1), 1–4.
  14. Ruff, K. J., Winkler, A., Jackson, R. W., DeVore, D. P., & Ritz, B. W. (2009). Eggshell membrane in the treatment of pain and stiffness from osteoarthritis of the knee: A randomized, multicenter, double-blind, placebo-controlled clinical study. Clinical rheumatology, 28(8), 907–914.
  15. Schauss, A. G., Stenehjem, J., Park, J., Endres, J. R., & Clewell, A. (2012). Effect of the novel low molecular weight hydrolyzed chicken sternal cartilage extract, BioCell Collagen, on improving osteoarthritis-related symptoms: A randomized, double-blind, placebo-controlled trial. Journal of Agricultural and Food Chemistry, 60(16), 4096-4101.
  16. Sengupta, K., Alluri, K. V., Satish, A. R., Mishra, S., Golakoti, T., Sarma, K. V., … Raychaudhuri, S. P. (2008). A double blind, randomized, placebo controlled study of the efficacy and safety of 5-Loxin for treatment of osteoarthritis of the knee. Arthritis research & therapy, 10(4), R85.
  17. Sengupta, K., Krishnaraju, A. V., Vishal, A. A., Mishra, A., Trimurtulu, G., Sarma, K. V., … Raychaudhuri, S. P. (2010). Comparative efficacy and tolerability of 5-Loxin® and Aflapin® against osteoarthritis of the knee: A double blind, randomized, placebo controlled clinical study. International journal of medical sciences, 7(6), 366–377.
  18. Sibilla, S., Godfrey, M., Brewer, S., Budh-Raja, A., & Genovese, L. (2015). An overview of the beneficial effects of hydrolysed collagen as a nutraceutical on skin properties: Scientific background and clinical studies. The Open Nutraceuticals Journal, 8(1), 29-42.
  19. Silvipriya, K., Kumar, K., Bhat, A., Kumar, B., John, A., & Lakshmanan, P. (2015). Collagen: Animal sources and biomedical application. Journal of Applied Pharmaceutical Science, 5(3), 123-127.
  20. Vasiliadis, H. S., & Tsikopoulos, K. (2017). Glucosamine and chondroitin for the treatment of osteoarthritis. World journal of orthopedics, 8(1), 1–11.
  21. Vishal, A. A., Mishra, A., & Raychaudhuri, S. P. (2011). A double blind, randomized, placebo controlled clinical study evaluates the early efficacy of aflapin in subjects with osteoarthritis of knee. International journal of medical sciences, 8(7), 615–622.
  22. Wandel, S., Jüni, P., Tendal, B., Nüesch, E., Villiger, P. M., Welton, N. J., … Trelle, S. (2010). Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: Network meta-analysis. BMJ (Clinical research ed.), 341, c4675.
  23. Zegels, B., Crozes, P., Uebelhart, D., Bruyère, O., & Reginster, J. (2013). Equivalence of a single dose (1200 mg) compared to a three-time a day dose (400 mg) of chondroitin 4&6 sulfate in patients with knee osteoarthritis. Results of a randomized double blind placebo controlled study. Osteoarthritis and Cartilage, 21(1), 22-27.
  24. Zhu, X., Sang, L., Wu, D., Rong, J., & Jiang, L. (2018). Effectiveness and safety of glucosamine and chondroitin for the treatment of osteoarthritis: a meta-analysis of randomized controlled trials. Journal of orthopaedic surgery and research, 13(1), 170.