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Questions and Answers
What is the primary function of anti-inflammatory herbal constituents?
What is the benefit of using herbal alteratives and hepatics in chronic inflammatory conditions?
How can herbs be used to alleviate pain and inflammation in the MSK system?
Which of the following herbs has been studied for its anti-inflammatory properties in the treatment of osteoarthritis?
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What is the role of cyclo-oxygenase and lipoxygenase enzymes in inflammation?
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What is the manifestation of the Heart in the body?
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What is the relationship between the Small Intestine and the Bladder?
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What is the function of the Small Intestine in relation to food and drink?
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What is the effect of Heart Qi Deficiency on sweat?
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What is the role of the Small Intestine in mental clarity and judgment?
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What is the primary benefit of incorporating exercise in the treatment plan for patients with osteoarthritis?
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What is the recommended approach to exercise for patients with osteoarthritis?
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What is the benefit of hydrotherapy in the treatment of rheumatoid arthritis?
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What is the recommended temperature application for an acutely inflamed joint?
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What is the benefit of tai chi in the treatment of osteoarthritis of the knee?
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Which of the following vitamins is also known as Cobalamin?
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What is the title of the book written by Katz?
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Which of the following is a systematic review of the literature on the prevalence and outcomes of anemia in rheumatoid arthritis?
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What is the title of the journal that published an article on the effects of the Mediterranean diet on rheumatoid arthritis prevention and treatment?
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Which of the following is a source cited in the references?
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What is the primary action of Curcuma longa (Turmeric)?
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What is the closest substitute for Ginkgo biloba (Ginkgo)?
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What is the part used for Curcuma longa (Turmeric)?
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What is the recommended daily therapeutic dose of Curcuma longa (Turmeric) in infusion or decoction?
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What is the action of Ginkgo biloba (Ginkgo) related to blood clotting?
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Which of the following remedies is characterized by a lack of internal heat but pains better by cold application?
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What is the peculiar characteristic of the tongue in Rhus Tox?
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Which of the following remedies is known for its shooting pains in the foot and limbs?
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Which of the following remedies is worse from continued motion?
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Which of the following remedies is known for its superstitious and ritualistic behavior?
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What is the mechanism of action of ASA on COX enzymes?
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What is the primary concern for patients taking Celecoxib?
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What is the primary mechanism of acetaminophen's analgesic and antipyretic effects?
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What is the optimal strategy for reducing the risk of GI bleeding in patients taking NSAIDs?
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What is the primary contraindication for ASA use in children?
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Study Notes
Botanical Treatment Strategy for Inflammation in the Musculoskeletal System
- Find and treat the underlying cause of inflammation, which may include toxicity, overuse, irritation, or infection
- Reduce inflammation
- Alleviate pain
- Restore damaged connective tissue
- Improve mobility and range of motion
Herbal Actions for Joint Pain and Inflammation
- Alteratives and hepatics: support metabolism and elimination, with a cleansing effect on the body
- Anti-rheumatics: help reduce or resolve symptoms of musculoskeletal disease
- Anti-inflammatories: modulate inflammation
- Anodynes/analgesics: alleviate pain
- Connective tissue tonics: strengthen and repair damaged connective tissue
- Diuretics: remove waste, such as uric acid
- Rubefacients and circulatory stimulants: promote circulation and delivery of healing factors
Herbal Anti-Inflammatories
- Reduce or resolve inappropriate inflammation
- Can have a general action or be tissue-specific, such as turmeric, licorice, hawthorn, and devil's claw
Mechanism of Action of Herbal Anti-Inflammatories
- Provide a demulcent or emollient action on inflamed tissues
- Inhibit cyclo-oxygenase and lipoxygenase enzymes to reduce inflammatory prostaglandin and leukotriene production
- Regulate inflammatory cytokine and interleukin production
- Detoxify the body to reduce toxic load and restore tissue function
Anti-Inflammatory Constituents
- Resins: anti-inflammatory, rubefacient (e.g., turmeric, devil's claw, frankincense)
- Salicylates: anti-inflammatory, analgesic, antipyretic (e.g., white willow, wintergreen)
- Volatile oils: anti-inflammatory, antimicrobial, rubefacient (e.g., turmeric, ginger)
- Saponins: anti-inflammatory, adaptogen, immunomodulator (e.g., licorice, wild yam)
- Mucilage: anti-inflammatory, demulcent, emollient, vulnerary (e.g., marshmallow, slippery elm)
- Sulphur: anti-inflammatory, anti-microbial, rubefacient (e.g., garlic, onion, mustard)
- Flavonoids: anti-inflammatory, anti-oxidant, anti-allergy (e.g., turmeric, licorice)
- Iridoid glycosides: anti-inflammatory (e.g., devil's claw)
Materia Medica for Joint Pain and Inflammation
- Arnica montana (topical)
- Boswellia serrata
- Capsicum frutescens (topical)
- Cichorium intybus
- Curcuma longa
- Dioscorea villosa
- Harpagophytum procumbens
- Olea europaea
- Rosa canina
- Salix alba
- Symphytum officinale (topical)
- Uncaria tomentosa/guianensis
- Urtica dioica
- Zingiber officinale
Harpagophytum Procumbens (Devil's Claw)
- Common name: devil's claw
- Family: Pedaliaceae
- Parts used: tuber (secondary roots)
- Main constituents: iridoid glycosides (harpagosides), flavonoids
- Main indications: arthritis (rheumatoid and osteoarthritis), tendonitis, musculoskeletal degenerative disease
- Main actions: significant anti-inflammatory action, anti-oxidant, anti-rheumatic, analgesic
- Safety concerns: high doses may cause transient mild GIT disturbance, headaches, conjunctivitis, tinnitus, tachycardia, rhinitis; use caution with anxiety, peptic ulcers, gallstones, Hx asthma, bleeding disorders, CHF, HTN, heart disease; CI in pregnancy and lactation
Curcuma Longa (Turmeric)
- Common name: turmeric
- Family: Zingiberaceae
- Parts used: rhizome
- Main constituents: curcuminoids (curcumin), volatile oils (zingiberene, turmerone), resins
- Main indications: rheumatic disorders (arthritis), cardiovascular disease by lowering cholesterol and TG, IBD
- Main actions: significant anti-inflammatory action via downregulation of COX-2, LOX, and inducible nitric oxide enzymes, hepatoprotectant, hypolipidemic
Topical Considerations
- Arnica montana
- Capsicum frutescens
- Curcuma longa
- Symphytum officinale
- Urtica dioica
- Viburnum spp.
- Zingiber officinale
- Castor oil
- Rosemary, wintergreen, peppermint, eucalyptus essential oils
TCM Heart Functions
- The Heart governs Blood and is responsible for its transformation from Gu-Qi into Blood.
- The Heart controls the circulation of Blood and the state of the Blood vessels.
- If the Heart Qi is strong, the Blood vessels will be in a good state, and the pulse will be full and regular.
- The Heart is reflected in the complexion, and its state can affect the distribution of Blood throughout the body.
- The Heart houses the Mind (Shen), which includes mental faculties, and is related to the mental and spiritual aspects of a human being.
- The Heart is responsible for mental activity, consciousness, emotional state, memory, thinking, and sleep.
- A strong Heart and abundant Blood lead to a normal mental activity, a balanced emotional life, clear consciousness, good memory, keen thinking, and good sleep.
- The Heart is related to Joy, and excessive excitement or craving can injure the Heart.
- The Heart opens into the tongue, controlling its color, form, and appearance, and affects speech.
- The Heart controls sweat, and its Qi Deficiency can cause spontaneous sweating, while a Yin Deficiency can cause night sweating.
TCM Small Intestine Functions
- The Small Intestine controls receiving and transforming food and drink from the Stomach.
- It separates the 'clean' (reusable) part from the 'dirty' part, and the 'clean' part is transported by the Spleen to nourish the body.
- The Small Intestine has a direct functional relation with the Bladder and influences urinary function.
- It separates fluids, further processing the 'dirty' fluids from the Stomach into a 'clean' part for excretion as urine and a 'dirty' part for excretion in the stools.
- The Small Intestine influences mental clarity and judgment, helping to distinguish options clearly in order to come to a decision.
Treatment Notebook
- A Treatment Notebook is a way to gather information in a case-based approach for easy access in practice.
- It should be started while learning about each case every week and will be beneficial for future practice as a Naturopathic Doctor (ND).
Components of a Treatment Notebook
- Pathophysiology of disease
- Signs and symptoms (SSx) of the disease
- Etiology, epidemiology, risk factors, and prognosis
- Differential diagnosis (DDx)
- Workup/labs
- Treatment Options:
- Nutrition
- Homeopathy
- Nutraceuticals
- Counselling
- Lifestyle
- Physical medicine / manipulation
- TCM/Acupuncture
- Prescription medications
- Botanical medicine
- Injection / IV therapy
Examples of Treatment Notebooks
- Medscape (https://reference.medscape.com/)
- ND Assist (https://www.nhpassist.com/database)
Exercise, Hydrotherapy, and Tai Chi for Arthritis
Benefits of Exercise
- Improve health and fitness while not injuring joints
- Strengthen muscles around joints
- Reduce pain and stiffness
- Help maintain bone strength
- Increase energy and improve mood
- Make it easier to sleep well
- Help control weight
- Improve balance
The "Right Kind" of Exercise
- Low impact (e.g., walking, recumbent cycling, exercising in water)
- Focus on range-of-motion, strengthening, and aerobic exercises
- Go slow, move gently, and mindfully
- Use heat before exercise and consider ice afterwards if joints are inflamed or swollen
Benefits of Exercise for Osteoarthritis
- Long-term walking and resistance-training programs slow functional decline
- Regular walking reduces levels of fatigue associated with RA
Benefits of Hydrotherapy
- Application of heat relieves joint pain and stiffness caused by RA and OA
- Cold is preferable for treatment of an acutely inflamed joint to help decrease pain and inflammation
- Hydrotherapy and water aerobics reduce RA symptoms of pain and joint tenderness while relieving tension and improving mood
Heat Application Methods for Hydrotherapy
- Fomentation / Hot compress
- Moist hot packs
- A hot shower
- Spas
- Ultrasonography
- Diathermy
Benefits of Tai Chi
- Tai chi is a potentially effective treatment for pain associated with osteoarthritis of the knee
- Tai Chi reduces pain in people with RA by 2.15 points on a scale of 0 to 10
Inflammatory Joint Conditions
- Malnutrition is common among patients with rheumatoid arthritis (RA), occurring in 26% of patients, and its severity increases with disease severity.
- Treatment goals for RA include addressing presenting symptoms, supporting full recovery, patient education, and monitoring and preventing complications.
Food Allergy and Sensitivity
- Food allergy occurs when the immune system mistakes a protein in food as harmful, releasing immunoglobulin E (IgE) and triggering symptoms such as abdominal pain, hives, or tingling in the mouth.
- Common food allergies include eggs, milk, fish, shellfish, peanuts, tree nuts, wheat, and soy.
- Food sensitivity is more common than food allergy and is harder to track, with symptoms such as cramps, bloating, and diarrhea that may not appear immediately.
- One-third of people with RA report that certain foods worsen their symptoms, with red meat and dairy known to trigger inflammation.
Special Diets
- The Mediterranean diet has been shown to reduce pain and improve physical function in people with RA.
- The Mediterranean diet is a plant-based diet that emphasizes the intake of foods such as olive oil, fish, and moderate amounts of red wine.
- Key components of the Mediterranean diet include eating primarily plant-based foods, replacing butter with healthy fats, using herbs and spices instead of salt, and eating fish and poultry at least twice a week.
- A small study found that a low-fat vegan diet improved RA joint pain, stiffness, and swelling, but there is not enough evidence to justify recommending a vegan diet for everyone with RA.
Supplements to Consider
- Fatty acids, particularly omega-3 fatty acids found in fish oil, have been shown to reduce joint pain and morning stiffness in RA.
- Folate supplements are recommended for people taking methotrexate, a common RA medication, as it can destroy folate.
- Iron supplements are recommended for people with anemia, which is common in patients with chronic inflammatory joint conditions such as RA.
Summary
- Key points for nutritional guidance in RA include considering food allergy and sensitivity, special diets such as the Mediterranean diet, and supplements such as fatty acids, folate, and iron.
Case Study
- Clara M, a 49-year-old woman with RA, should take folate (5mg folic acid) supplements to counteract the effects of methotrexate on folate levels.
Outcome Measures
- Increase pain-free range of motion
- Improve pain in joints
- Prevent progression to physical degeneration
Relevant Botanical Actions to Consider
- Anti-inflammatory
- Hepatic
- Alterative
- Diuretic
- Circulatory tonic
- Analgesic
- Adaptogen
Featured Herbs by Botanical Action
Alterative
- Nettle leaf (Urtica dioica folia)
- Dandelion leaf (Taraxacum officinale)
- Yarrow (Achillea millefolium)
- Berberis vulgaris (Barberry)
- Bupleurum sinensis (Bupleurum)
- Glycyrrhiza glabra (Licorice)
Anti-inflammatory
- Turmeric (Curcuma longa)
- Devil's claw (Harpagophytum procumbens)
- Frankincense (Boswellia serrata)
- Polygonum cuspidatum (Japaneses knotweed)
- Cat's claw (Uncaria tomentosa)
- Polygonatum biflorum (Solomon's seal)
Analgesic
- Kava kava (Piper methysticum)
- Cannabis (Cannabis indica)
- Cayenne (Capsicum annua)
- Valerian (Valeriana officinalis)
- Jamaican dogwood (Piscidia piscipula)
- Wild lettuce (Lactuca virosa)
Adaptogen
- Ganoderma spp. (Reishi, Ling zhi)
- Cordyceps sinensis (Cordyceps)
- Innonotus obliqus (Chaga)
- Codonopsis pilosula (Dan shen)
- Astragalus membranaceus (Huang qi)
- Panax quinquefolia (NA ginseng)
Herb Selection
- Formula: Polygonum cuspidatum 30, Harpagophytum procumbens 20, Gingko biloba 30, Actea racemosa 10, Curcuma longa 10
- Dosage: Tincture or powder: 1 to 2 tablespoons (15–30 mL) a day, ideally in a mug of warm water between meals
- Cautions and Contraindications: Ginkgo may cause mild stomach discomfort and, occasionally, headaches
Other Effective Therapies
- Contrasting hydrotherapy
- Inclusion of healthy fats and oils
- Ensuring appropriate amounts of protein
Botanicals in Joint Pain
Boswellia serrata (Frankincense)
- Primary Actions: Antimicrobial, anti-inflammatory, astringent
- Constituents: Resins, boswellic acid, volatile oils
- Indications: Inflammatory joint conditions, IBD, topical antimicrobial
- Cautions and Contraindications: Considered safe, though not generally taken internally in large amounts
- Daily Therapeutic Dose: Tincture: 2–4 mL (1:5 in 90%), Infusion or Decoction: 300–3000 mg
Capsicum frutescens (Cayenne)
- Primary Actions: Stimulant, circulatory tonic, rubefacient, sialagogue, libido tonic
- Constituents: Capsaicinoids (capsaicin), steroidal saponins
- Indications: Circulatory deficiencies, arthritic conditions, pain relief, depression
- Cautions and Contraindications: Non-toxic, but large doses will cause sweating and possible syncope
- Daily Therapeutic Dose: Tincture: 1–5 mL (1:5 in 25%), Infusion or Decoction: 1–2 g powder
Curcuma longa (Turmeric)
- Primary Actions: Anti-inflammatory, mild antimicrobial, carminative, circulatory tonic
- Constituents: Phenolic antioxidants, curcumin, volatile oils, starches
- Indications: General inflammatory conditions, OA and RA, possibly cancer lesions (topical), stomach ulcers and dyspepsia
- Cautions and Contraindications: Broadly considered safe, though acts as a mild inhibitor of phase I and inducer of phase II liver conjugation
- Daily Therapeutic Dose: Tincture: 8–24 mL (1:5 in 30%), Infusion or Decoction: 8–20 g dried root or powder
Rheumatoid Arthritis Symptoms
- Tender, warm, swollen joints
- Joint stiffness that is worse in the mornings and after inactivity
- Fatigue, fever, and loss of appetite
- Early stages affect smaller joints, particularly finger and toe joints
- Symptoms often spread to wrists, knees, ankles, elbows, hips, and shoulders
- Symptoms usually occur in the same joints on both sides of the body
Remedies for Knee Pain
- Bryonia: White Bryony
- Rhus Toxicodendron: Poison Oak
- Ledum: Marsh Tea
Bryonia
- Acts on serous membranes and organs they contain
- Tendons, ligaments, or connective tissue
- Joint and muscle pain and stiffness, worse with any motion
- Aggravation: slightest motion, heat (except local heat)
- Amelioration: rest, strong pressure, lying on painful side, sweating
- Concomitants: strong thirst, irritability, business thoughts, attempt to achieve absolute immobility
Rhus Toxicodendron
- Joint/tendon/muscle ailments with stiffness and pain
- Affinity: skin, blood, mucous membranes, glands, nerves
- Worse from: continued motion, heat, warm drinks, rubbing, change of position
- Generalities: aversion to certain foods, desires certain foods, worse from certain foods
- Mental picture: restless, busy, superstitious, ritualistic, or compulsive behavior
Ledum
- Lack of internal heat, but pains better with cold application
- Gouty joints, pains from the feet upward (ascending pains)
- Rheumatism alternating with hemoptysis
- Worse from: heat, night in bed, motion, covering inflamed parts
- Better from: cold, soaking in cold water
- Characteristics: shooting pains in foot, limbs, small joints; ankles easily sprain
Differential Diagnosis
- Bryonia: rheumatism with excruciating, stitching pain
- Rhus Toxicodendron: main remedy in rheumatism
- Ledum: acute gouty pain of the knee, ankles swollen, shoulders, ball of great toe
NON-OPIOID ANALGESICS AND ANTI-INFLAMMATORIES
NON-STEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)
- NSAIDs are one of the most commonly prescribed medications for pain and inflammation.
- They make up 5-10% of all medications prescribed each year.
- Up to 96% of patients over the age of 65 use NSAIDs in the family practice setting.
MECHANISM OF ACTION
- COX-2 prostaglandins are inflammatory and participate in inflammatory responses which can produce pain.
- COX-1 inhibition leads to ulcers and increases the risk for major GI bleeds.
- COX-2 inhibition is desirable for anti-inflammatory effects.
ACETYLSALICYLIC ACID (ASA)
- ASA causes irreversible inhibition of COX by covalently bonding its acetyl group to the active binding site of COX.
- ASA has a short plasma half-life as it is rapidly hydrolyzed to salicylic acid by plasma esterase.
- Eliminated in the urine after conjugation (primarily to glycine).
- Rate of excretion is affected by urine pH.
- Contraindicated in children with viral infections.
- Adverse effects: GI irritation/ulcers/bleeding, tinnitus, high doses can cause hyperventilation, fever, dehydration, metabolic acidosis, impairment of hemostasis, and hypersensitivity reactions.
IBUPROFEN
- Adverse effects: GI irritation, nausea, dyspepsia, bleeding, hepatic toxicity, and renal toxicity including acute renal failure if dehydration occurs.
ACETAMINOPHEN
- Little effect on COX-1 or COX-2, but has affinity for COX-3, which may explain its analgesic and antipyretic effect.
- Rapidly absorbed from the gut, with minimal plasma protein binding, and widely distributed to peripheral tissue and the CNS.
- Toxic intermediate formed with CYP1A2, 2E1, 3A isoenzymes, normally conjugated with glutathione and renally excreted.
- Glutathione depletion can lead to hepatic necrosis.
CELECOXIB
- Selective COX-2 inhibitor with potent anti-inflammatory activity without significant GI toxicity.
- Increased risk of cardiovascular disease and mortality.
- Does not inhibit platelet aggregation.
GASTROPROTECTION
- Risk factors for major GI bleeding: increased age, concomitant use of systemic corticosteroids or warfarin, and history of GI bleeding or peptic ulcer disease.
- Strategies to reduce serious adverse effects: using COX-2 selective NSAIDs, prostaglandin analogues (e.g., misoprostol), and proton pump inhibitors (e.g., omeprazole).
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Description
Learn about the botanical treatment strategies for inflammation in the musculoskeletal system and identify herbal actions beneficial for joint pain and inflammation.
