Examining the evidence for joint pain supplements

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The Naked Truth

Examining the evidence for joint pain supplements

by Douglas Kalman MS, RD, FACN

 

When we created T-Nation, one of our goals was to act as a watchdog for the

supplement industry. So far, we've exposed frauds, cut through the hype and

provided readers with the info they need to make smart supplement choices.

 

Now we'd like to take our role one step further. We're regularly reviewing

supplements from various companies. If we feel they're worth buying, we'll

let you know. If they stink, we'll tell you that too.

 

In this installment, Douglas Kalman takes a look at products for joint

pain, a popular and rapidly growing category of supplementation. Do they

really work? Doug digs deep into the latest research to find out!

 

Oh, My Achin' Joints!

 

As we age, many start to notice that their joints ache. Not only that, but

muscles ache that never used to ache before. Some would say these symptoms

are just part of the natural fabric of aging (for any of you older than

30), but could these symptoms also be consistent with various forms of

osteoarthritis?

 

Osteoarthritis (OA) often manifests itself with joint pain and

inflammation, especially in the knees or hips. At times, we do develop OA

in other areas of the body, such as the hands, shoulders or minor joints

such as the ankle, but these are less common.

 

These days, you can't read a newspaper or watch TV, especially during a

sporting event, without seeing an ad for an over-the-counter medicine (such

as Tylenol or Advil) or a prescription medication for reducing the symptoms

of OA (such as Vioxx or Celebrex). However, mounting evidence exists

demonstrating that certain natural extracts may work just as well as

prescription agents.

 

Let's examine the evidence.

 

 

Shellfish Extract Anyone?

 

We first ate fish because our moms told us that fish is " brain food " (and

mom was partially right). Now, we consume fish because it's heart healthy,

especially the fatty fish that comes from cold waters like Pacific salmon.

 

However, did you ever wonder about the health effects of shellfish? Well,

for the most part, if you eat shrimp, lobster or the like, they'll have an

equivocal effect on your cholesterol profile and heart disease risk. In

other words, if you belong to the 15% or so of the population that's

cholesterol sensitive, they'll raise your cholesterol slightly and possibly

elevate the risk of heart disease. (1)

 

While we as a nation consume a lot of shrimp, the shells are often thrown

out ? that is until recently, when it was realized that certain medicines

and natural agents could be extracted from these shells.

 

One specific extract is the popular dietary supplement, glucosamine. That's

right, glucosamine is a crustacean shell extract.

 

 

Glucosamine: The Evidence for Effectiveness

 

In osteoarthritis, one of the reasons the joints begin to ache is because

the cartilage lining (or cushion between the joints) is either worn away or

has subnormal padding in the first place. This loss of padding between the

joints produces joint space narrowing.

 

In clinical research, one of the objective measurements used by scientists

to see if an OA medicine or natural adjunctive agent works is to examine

its effects on joint space. If glucosamine has an effect on the joint

spacing, it's thought to have a structural effect (which may also reduce

the symptoms of OA).

 

A recent meta-analysis conducted by the Faculty of Medicine at the

University of Liege in Belgium evaluated if glucosamine sulfate had any

structural or symptomatic effects in prior published OA clinical trials.

Most of the better clinical studies that evaluate any potential medicine or

adjunctive agent for OA use the subjective Western Ontario MacMaster

University Osteoarthritis Index (WOMAC).

 

The WOMAC is known as the gold standard in OA research. This specific

questionnaire assesses how the disease or its treatment intervention works

for reducing pain and how it affects activities of daily living. For many,

the OA discomfort they experience is painful, makes walking stiff, and

interferes with their abilities to do normal everyday things.

 

This 2003 meta-analysis analyzed all published research studies from 1980

to 2002 that assessed the effects of glucosamine on arthritis. The results?

Glucosamine had a highly significant effect on every imaginable aspect

measured! It has helped joint space narrowing and quality of life as

assessed by the WOMAC. It was also considered safe and had a pain reducing

effect. (2)

 

Without doubt, glucosamine works in people with osteoarthritis. The

conclusion of this meta-analysis was supported by a secondary review of

complementary and alternative medications (CAM therapy) for those with

osteoarthritis. In this systematic review, the University of Maryland

determined there was good evidence to support the claims made on

glucosamine for OA . (3) What's even more startling is that glucosamine has

equally apparent efficacy as ibuprofen for pain relief, without the same

gastrointestinal side effects possible with ibuprofen. (4)

 

But can glucosamine be good for pain in those people who don't have OA? In

short, it appears so. However, before any blanket endorsement is decided

upon, a review of the non-OA research with glucosamine is warranted.

 

The Department of Human Movement and Exercise Sciences tested this out.

They took 46 people who complained of having regular knee pain (with no

definitive diagnosis of OA) and split the 46 subjects into two ? the reason

was to see if glucosamine as compared to placebo could have any discernable

difference in the amount of pain felt by the subjects.

 

The group randomized to receive the glucosamine was given a high dose of

2,000 mg per day, while the placebo group received a sugar pill. The study

participants answered various standardized questionnaires and took physical

tests. At the end of the study, the researchers found that those taking

glucosamine had some degree of pain relief and improved function in terms

of their knee function. It was also noted that it wasn't until the

eight-week mark where a difference was detectable to the research staff. (5)

 

In short, glucosamine appears to have a positive effect on the quality of

life in those with knee pain.

 

 

What About Chondroitin?

 

Good question. In fact, you seldom see glucosamine without its sidekick

chondroitin close by. Many of the published studies focus in on the

glucosamine fraction; however, chrondroitin is perhaps underestimated.

 

 

The chrondroitin moiety is one that's chiefly derived from cows. In fact,

it's typically extracted from the trachea, although a Kosher, vegetarian

source is now also being used in the marketplace.

 

Chondroitin has synergistic data (with glucosamine) and individual data

supporting its use in osteoarthritis. Laboratory clinical trials have shown

that this extract stimulates the growth of new cartilage cells

(chondrocytes). Full clinical trials have also shown it to be effective for

reducing the pain associated with OA. (2, 6)

 

A new form of chondroitin extracted from shark cartilage has recently been

tested and the results indicate it's well absorbed, thus this extract may

too offer benefits in those with OA. (6)

 

But Wait!

 

Wasn't there a T-mag article a while back stating that glucosamine and

chondroitin could raise blood sugar? Yes, and this is something that's

generated a lot of buzz.

 

Glucosamine is a combination of a sugar and amino acid molecule. This

molecule is absorbed in the body through the hexosamine pathway (over

activity of this pathway disrupts insulin activity). (7) Glucosamine can

theoretically lead to an increase in blood sugar in people with diabetes.

 

Animal research has raised the possibility that glucosamine could

contribute to insulin resistance (a condition in which the body's insulin

becomes less effective at fueling the body's cells with sugar). Some

doctors speculate this might result from glucosamine's ability to interfere

with an enzyme needed to regulate blood sugar levels.

 

A recent study of people with type-2 diabetes showed no significant

differences in the pre- and post-study hemoglobin A1c concentrations

(measure of glucose control) of those who took glucosamine-chondroitin and

those who took placebo for 90 days. (8) A separate study found that these

agents don't affect insulin activity or sensitivity in normal adults. (9)

Therefore, this concern about the potential of glucosamine to negatively

impact blood sugar appears to be unwarranted.

 

If you do have diabetes and use these agents, there's nothing wrong with

monitoring if you're affected by glucosamine/chondroitin and to report the

results to your physician. Glucosamine and chondroitin have no known

impacts on weight loss, so for those who watch their carbohydrates, there's

no need to worry.

 

Brands tested include Dona, Move Free, and Cosamin.

 

 

To the Devil with Your Pain!

 

Ever heard of Harpagophytum procumbens? Its popular name is devil's claw:

 

 

 

From a genus standpoint, devil's claw is considered a tuber (like the

lovely potato). In Germany, it's used in the adjunctive treatment of

rheumatoid arthritis and in cases of low back pain.

 

A recent publication described a study of devil's claw in 75 adults who had

diagnosed arthritis of the knee or hip. In order to fully determine if the

herbal preparation offered any benefit, the WOMAC scale was used and

subjects were also asked to rate their pain over time (twelve weeks).

 

The authors of this study concluded that devil's claw reduced pain by about

25% and enhanced the ability for the subjects taking it to be more

physically active. In fact, when the physicians administered a pain test,

those receiving the devil's claw had a 45% improvement as compared to

taking nothing at all. In all, the only negative complaints were dyspepsia

(indigestion) and a sensation of fullness. (10)

 

In another study, the effectiveness of devil's claw was evaluated in both

older and young adults who suffered from low back pain or osteoarthritis of

the knee or hip. This eight week study found that by the forth week, those

getting the active product experienced improvement and the improvement grew

over time.

 

The authors stated that 50-70% of the people who were given devil's claw

had a positive response with only minor noted side effects. (11)

 

Branded devil's claw used in research: Doloteffin ? 2400 mg extract daily

containing 50 mg harpagoside.

 

 

Other Natural Occurring Agents

 

In New Zealand, an extract of the green-lipped mussel is commonly used for

the relief of pain and as an anti-inflammatory agent. (12) This extract has

been shown in clinical trials to possess anti-inflammatory activity in both

animals and humans. The evidence points to a positive effect (disease

activity reduction) in osteoarthritis, rheumatoid arthritis, asthma, and in

other inflammatory conditions.

 

In a recent study of 60 subjects who had osteoarthritis of the knee or hip,

the green-lipped mussel extract led to a significant improvement in every

category tested and evaluated. By the time the study concluded (eight

weeks), 80% of the subjects taking the product experienced significant

improvement in pain and improvement in joint function. (13)

 

The only green-lipped mussel product tested (Lyprinol) appears to be the

one to watch. The data for its effectiveness is accumulating and has been

validated by researchers outside of New Zealand.

 

 

 

It's also possible that omega-3 fatty acids (n-3 fatty acids), which are

clinically used for a wide range of conditions, may offer some benefit to

those with osteoarthritis. Besides being good for the heart (a daily intake

of at least one gram reduces the risk of heart disease), a recent study

found that supplementation with the omega-3 fatty acids (and not omega-6)

reduced degenerative and inflammatory aspects of chondrocyte metabolism,

while having no untoward effects on the tissue.

 

 

 

Thus, it appears that the daily intake of omega-3 fatty acids through food

or dietary supplements has a beneficial effect of slowing and reducing

inflammation, which acts in the pathogenesis of degenerative joint diseases.

 

Omega-3 fatty acids are polyunsaturated fats (PUFA). This type of PUFA is

found in fatty fish, fish oil supplements and in flax seeds. About 10% of

your fat intake should come from this type of PUFA source.

 

One last product worthy of mention is one that hasn't received much

attention in the popular media, but perhaps it should. Active absorbable

algal calcium (AAA-Ca) in one recent study was found to significantly

reduce pain. The dose of AAA-Ca used was 900 mg.

 

However, the weakness in the 80-subject study was that the product tested

wasn't tested alone; it was combined with collagen (3.5 grams in fact).

(14) Since the data does appear to support the need for future studies,

this form of calcium is worthy of that research and may be one to watch for

future usage.

 

 

Let's Recap

 

Many studies have found that there are a plethora of natural agents that

may offer some benefit against joint pain and osteoarthritis. As we age,

issues surrounding quality of life become more important. For some, being

as physically active as they may have been when younger results in a

greater duration of muscle soreness, joint pain and sometimes the onset of

osteoarthritis.

 

The strongest data appears in support for glucosamine and chondroitin,

while a specific type of devil's claw also has mounting evidence of its

worthiness.

 

You should also be including omega-3 fatty acids in your everyday diet for

its many positive health benefits. For those of you with joint pain or

osteoarthritis, this adds to the long list of reasons for you to add On-3

fatty acids to your diet or supplement routine.

 

Lyprinol and algal-calcium also appear to be of interest to those in the

medical community as helpful adjuncts in the fight against osteoarthritis.

 

If any of these natural products interest you, take the time to learn more

about them. Being proactive in your own healthcare is the best way to take

your health back from today's society of toxicity. For those with

osteoarthritis or if you're looking to prevent it, the argument for

incorporating any of these natural adjunctive therapies into your life

seems to be a no-brainer.

 

 

References

 

1) De Oliveira e Silva ER, Seidman CE, Tian JJ, Hudgins LC, Sacks FM,

Breslow JL. Effects of shrimp consumption on plasma lipoproteins. Am J Clin

Nutr. 1996;64(5):712-7.

 

2) Richy F, Bruyere O, Ethgen O, et al. Structural and symptomatic efficacy

of glucosamine and chrondroitin in knee osteoarthritis: a comprehensive

meta-analysis. Arch Intern Med 2003;14:163(13):1514-1522.

 

3) Socken KL. Selected CAM therapies for arthritis-related pain: the

evidence from systematic reviews. Clin J Pain 2004;20(1):13-18.

 

4) Ruane R, Griffiths P. Glucosamine therapy compared to ibuprofen for

joint pain. Br J Community Nurs 2002;7(3):148-152.

 

5) Braham R, Dawson B, Goodman C. The effect of glucosamine supplementation

on people experiencing regular knee pain. Br J Sports Med 2003;37(1):45-49.

 

6) Volpi N. Oral absorption and bioavailability of icthyic origin

chondroitin sulfate in healthy male volunteers. Osteoarthritis Cartilage

2003;11(6):433-441.

 

7) Pang Y, Bounelis P, Chatham JC, Marchese RB. Hexosamine pathway is

responsible for inhibition by diabetes of phenylephrine-induced inotropy.

Diabetes 2004;53(4):1074-1081.

 

8) Scroggie DA, Albright A, Harris MD. The effect of

glucosamine-chondroitin supplementation on glycosylated hemoglobin levels

in patients with type II diabetes mellitus: a placebo-controlled, double

blinded, randomized clinical trial. Arch Intern Med 2003;163(13):1587-1590.

 

9) Pouwels MJ, Jacobs JR, Span PN, Lutterman JA, Smits P, Tack CJ.

Short-term glucosamine infusion does not affect insulin sensitivity in

humans. J Clin Endocrinol Metab. 2001;86(5):2099-103.

 

10) Wegener T, Lupke NP. Treatment of patients with arthritis of hip or

knee with an aqueous extract of devil's claw. Phytother Res

2003;17(10):1165-1172.

 

11) Chrubasik S, Thanner J, Kunzel O, Conradt C, Black A, Pollak S.

Comparison of outcome measures during treatment with the proprietary

Harpagophytum extract Doloteffin in patients with pain in the lower back,

knee or hip. Phytomedicine 2002;9(3):181-194.

 

12) Halpern GM. Anti-inflammatory effects of a stabilized lipid extract of

Perna canalicus (Lyprinol). Allerg Immunol 2000;32(7):272-278.

 

13) Cho SH, Jung YB, Scong SC, Park HB, Byun KY, Lee DC, Song EK, Son JH.

Clinical efficacy and safety of Lyprinol,a patented extract from New

Zealand green-lipped mussel (Perna Canaliculus) in patients with

osteoarthritis of the hip and knee: a multicenter 2-month clinical study.

Allerg Immunol 2003'35(6):212-216.

 

14) Fujita T, Ohue M, Fujii Y, Miyauchi A, Takagi Y. The effect of active

absorbable algal calcium (AAA Ca) with collagen and other matrix

compoenents on back pain as measured by skin impedance. J Bone Miner Metab

2002;20(5):298-302.