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Acupuncture and Arthritis
29 January 2005
 
For many people with joint pain, these past few months have been very disturbing. Most of the medications commonly prescribed to relieve inflammation in joints, referred to in the literature as non-steroidal anti-inflammatory drugs (or NSAIDs), have been found to have dire side effects. Initially the bad news was the increased incidence of serious heart disease in patients taking the COX-2 class of NSAIDs, especially Vioxx and Celebrex. However the same cardiovascular problems were later reported for the older NSAIDs, including many of the commonly used over the counter drugs like Motrin and Aleve.

By coincidence, just when the alarming news about these drugs was made public, good news appeared about a treatment alternative. The Annals of Internal Medicine published a large study that demonstrated the efficacy of acupuncture in the treatment of arthritis of the knee.

In light of these developments, this newsletter will explore joint pain from the Western and Chinese medical viewpoints. Both systems provide means by which we can be proactive about dealing with the pain and progression of degenerative joint disease. Later in the newsletter some of these treatment options will be discussed.

Since I have osteoarthritis, I am especially engaged by this subject and have studied treatment options for some years. Many of you know I had a total hip replacement in 2003. Anyone interested in my personal joint disease story can go to my website Dancerhips.com:
http://www.dancerhips.com/

Topics:
  1. Scope of the problem
  2. Western perspective on joint pain and treatment
  3. Chinese perspective on joint pain and treatment
  4. The Acupuncture Study
  5. Integrative approaches to the treatment of joint pain
1. Scope of the problem
In America one out of every three adults has some kind of arthritis. In 2002 that was 70 million people. More than half of these people are under the age of 65. As baby boomers age, these numbers can only increase. The impact of this epidemic is enormous - not only in the loss of quality of life for the individual as joint dysfunction interferes with simple tasks of daily living (like dressing and walking), but also in the loss of productivity to the work force. Arthritis is second only to heart disease as a cause of work disability.
Source: The Arthritis Foundation


2. Western perspective on joint pain and treatment
Viewed from the Western perspective, joint pain is primarily from inflammation. This can mean inflammation of any of the components of the joint area which includes the tendons and the bursa (fluid filled, pad like sacs that cushion joints). Inflammation of these non-bony areas, called tendonitis and bursitis respectively, is usually from overuse and often responds to conservative treatment such as ice, rest and immobilization. Inflammation of the bony articulations is referred to as arthritis, and can have many causes. In Osteoarthritis, the most commonly seen variety, inflammation results from joint deterioration and is the focus of this newsletter. Arthritis is also seen in auto-immune diseases like Lupus, Rheumatoid arthritis and Scleroderma and as a manifestation of problems in body chemistry as in Gout.

Osteoarthritis describes degeneration of a joint (or multiple joints) with subsequent pain, decreased range of motion and, sometimes, swelling. Most often the deterioration is from wear and tear as the body ages. The appearance of arthritis in a younger person can be the result of a previous injury or trauma. (In my own case, I wore out my hip joints by decades of ballet.) As the joint changes, the cartilage that lubricates the joint capsule is lost and the bones begin to grind together. Obesity accelerates joint deterioration as hips, knees and ankles need to bear greater loads and thus grind down sooner.

Western treatment is aimed at decreasing inflammation. The COX-1 and COX-2 drugs (NSAIDs) were specifically developed to interfere with the production of compounds released into the blood stream during the inflammatory process that cause pain.

Other pharmaceutical treatment strategies do exist. Steroids are strongly anti-inflammatory but have too many serious side effects to be used in a chronic situation. Tylenol (acetaminophen) is not an anti-inflammatory medication so, while it reduces pain, it is not as effective as the NSAIDs in treating arthritis. Other pain medications, with no anti-inflammatory effects like narcotic analgesics, are contraindicated because of their addictive properties.


3. Chinese perspective on joint pain and treatment
Acupuncture and Chinese herbs have been used successfully to ameliorate joint pain long before the existence of Western medicine. Treatment is designed to meet the unique presentation of each patient. Whereas in the West we tend to treat all osteoarthritis with the same medications, usually NSAIDs, there is not “one size fits all” in Chinese Medicine.

Joint pain is thought to be the result of blockage of the flow of Qi, the life force energy. This blockage can be caused by the invasion of pathogenic temporal conditions including wind, cold, damp or damp-heat. The clinical manifestations of the resultant “Bi” syndromes, that is, whether the joint is cold or hot, swollen stiff, etc., will depend on the pathogenic influence. The treatment is designed to address the specific underlying Qi disturbance that occurs in each presentation.

Acupuncture is unable to change the underlying anatomy of a degenerated joint. However the amount of pain occurring in an area may be exacerbated if blocked Qi exists there. Acupuncture improves the flow of Qi through the affected area, along with the fluids that nourish the joint. This alone can result in significant relief.

However, the benefits of the acupuncture treatment do not end there. Every acupuncture treatment that is done in accordance with the principles of Traditional Chinese Medicine must treat the whole person. The practitioner works to correct the underlying Qi disharmonies and thus impact all the body's systems. The arthritic patient may get significant relief as a result of this optimization.

Extensive research has shown that acupuncture treatment releases endorphins. Although their presence is temporary, these neurotransmitters help us to deal with chronic discomfort by improving our mood.


4. The Acupuncture Study
It was very gratifying to finally see a large research study that confirms what we already know: that acupuncture decreases pain and increases mobility in patients with arthritis.

The Annals of Internal Medicine study (Dec 2004; 141:901-911) followed 570 patients with arthritis of the knee who were randomly divided into three groups: one group received real acupuncture weekly, a control group received “sham” needle treatment that mimicked real acupuncture, while a third group received education and counseling. All were allowed to continue taking whatever medications they were using.

Interestingly, the patients in the "sham group" did report a reduction in pain, but significantly less than the group getting true acupuncture. The group receiving the genuine treatment reported 40% improvement in symptoms. These patients showed an improvement in function by week 8 and a decrease in pain by week 14. Both the placebo and real needle treatments were more effective in relieving symptoms than education.

A significant finding of this study, in light of the news about NSAIDs, was the absence of side effects from the treatment. Acupuncture was found to be safe as well as effective.

At Turning Point we have some very good outcomes treating arthritis with acupuncture, especially arthritis of the knee. One such success story is of a famous ballroom dancer, then in his 50s, who I treated for debilitating knee pain.  He was able to avoid knee replacement surgery for another decade - dancing all the while.


5. Integrative approaches to the treatment of joint pain
I am a Western trained physician and acupuncturist with osteoarthritis. I have tried almost everything to deal with my situation. When all else failed I had a hip replacement and I am thrilled that Western medicine has such a miracle cure. But it is really radical surgery and the prosthetic joint has a limited life-time so that I, and many other younger recipients, can anticipate a repeat surgery in the future.

So what is a good approach to dealing with degenerative joint pain?
I recommend using what my physical therapist refers to as a “combo plate”: choosing those elements that work for you to address your joint problem. Some of those elements include acupuncture, weight control, diet, physical exercise, bodywork, stress reduction and taking supplements.

Weight control
Low body weight is of paramount importance in protecting weight bearing joints of the lower body. This is of special importance to those baby boomers who still like to run or play tennis or other impact sports. Any increase in body weight exponentially impacts the forces on the hip joints. The same is true for knees, as any overweight person will tell you when he/she tries to get out of a chair.

Diet
A healthy diet with plenty of colorful fruits and vegetables and whole grains is recommended. The reasoning behind this is that these foods (since they are high in beta carotene, etc.) help the body deal with oxidative ("free radical") stress, which is known to wear down bone. To address inflammation, foods with high levels of Omega 3 fatty acids, such as, flax seed oil, salmon (not farmed), tuna, and sardines, should be emphasized.
(See this page for guidelines of safe mercury levels in fish.)
Fresh pineapple contains Bromelain, an enzyme that reduces inflammation.
As in all healthful diets, saturated fats and refined sugars are to be avoided.

Exercise
The value of exercise cannot be overstated. Exercise increases mobility, flexibility and stamina, improves overall energy and is a mood elevator. As painful as it may be, it is critical to keep a joint mobile. Strengthening the muscles around the affected area promotes better function and stabilization. Burning calories will help with weight management.
Try to do something you like so you will stick to it. Swimming is especially conducive since the water supports the body weight allowing for greater range of motion. Some pools offer special water arthritis classes.

Eastern forms of exercise like Qi Gong, Tai Qi and yoga emphasize a mind-body connection and work on deeper levels of healing while the body gets stronger and more limber. I particularly recommend Iyengar style yoga for people with joint problems since great care is taken to assure proper musculo/skeletal alignment in the postures. Props such as blocks, straps and bolsters, etc., are used to assist the student in gaining ease in the posture.

You can read about other exercise options including Pilates, Alexander technique, Mind-Body Centering on the dancerhips.com website.

Bodywork
Hands-on body work, e.g., massage, chiropractic, physical therapy, osteopathy, etc. helps with alignment and mobility. Deep tissue manipulation frees muscles that are in spasm. A good practitioner can mobilize stiff joints and correct spinal alignment that has been altered as the body attempts to compensate for impaired function.

Stress reduction
Frequent readers of this newsletter have read about the benefits of acupuncture, yoga, Tai Qi, Qi Gong, breathing exercises, meditation, psychotherapy, etc., to balance our Qi and allow us to be calmer and more centered. These practices also address problems of anxiety and depression. Changing our mental outlook can influence how we perceive pain.

Supplements
Millions of dollars are spent annually by people with joint pain seeking relief. Many claims are anecdotal and unsubstantiated medically. Be sure to have a skilled practitioner guide your choices. I have tried only some of the options and will recommend these. Many of the products mentioned are available at Turning Point since I tend to stock all the supplements I use.
(I am not affiliated with any of the companies that manufacture these.)
 
Here is a partial list of supplements that can treat joint pain:
1. Glucosamine Sulfate and Chondroitin Sulfate
Many people find taking this compound gives them relief from pain. I never had this experience but I think the literature is persuasive enough to take it to protect further joint deterioration.

Glucosamine is found in many body tissues. It is necessary for the biosynthesis of collagen and helps give tissue its flexibility and resilience. Much less research has been done on chondroitin, but it is thought to block the enzymes that break down collagen. Both compounds help cartilage absorb water thus increasing its lubrication and shock absorption.
Glucosamine is extracted from shellfish, so people with this allergy should take only chondroitin.

2. Multivitamins and Anti-oxidants
In addition to a good diet, we can protect cartilage by taking supplements to reduce oxidative stress.  These include vitamins and mineral, such as vitamin C, vitamin E (use mixed tocopherols), carotenoids and selenium, along with dietary extracts, such as the flavonoid quercetin, proanthocyanadins and green tea polyphenols.
I get all these in one product: Quercenol by White Tiger.
 
3. Calcium
Living bone is always in the process of renewing itself. Calcium is vital for the laying down of all new bone. Calcium supplements are especially important for peri-menopausal and menopausal women at risk for osteoporosis. I like calcium hydroxyapatite since it is easily absorbed. All calcium should be taken in divided doses and with food since stomach acid is necessary for assimilation.

5. Herbal remedies
Chinese herbal formulas have a long history of usage for joint disease. As with acupuncture there is no one formula that is right for everyone with the same complaint. Your practitioner will evaluate your underlying energetic imbalance and pick the appropriate herbs.
 
Many individual herbs have also been found to help joint pain. Some known to have anti-inflammatory and antioxidant properties include Boswellia, turmeric, ginger and cayenne. Many companies have combine these herbs into one product, e.g., Metagenics Inflavonoid Intensive Care.
 
Kaprex, a new herbal product from Metagenics, compared favorably to Celebrex in a recent (but small) study with regard to pain relief and GI protection. Kaprex consists of extracts from hops, rosemary and olive leaf.   

Before my surgery I did not find any herbal product very effective because the joint degeneration was too severe. However, I am currently taking Kaprex to manage the mild osteoarthritis I have in my spine and un-operated hip. I find Kaprex helpful enough that I do not have to take NSAIDs like Vioxx, Motrin, etc.

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