Botanicals in Joint Pain PDF

Botanicals in Joint Pain Chris Pickrell, ND, Herbalist, TCM Practitioner Key Actions: Hepatic, Anti-inflammatory The cause of the joint pain dictates the approach to treatment: Treat RA as you would any condition of...

Botanicals in Joint Pain Chris Pickrell, ND, Herbalist, TCM Practitioner Key Actions: Hepatic, Anti-inflammatory The cause of the joint pain dictates the approach to treatment: Treat RA as you would any condition of immune-mediated inflammation Treat OA or degenerative conditions by promoting circulation Key treatment principles: Promoting blood flow through the joint is always the best treatment Use topical and local treatments like a cayenne salve or essential oils of eucalyptus, mint, and wintergreen for acute pain relief More inflammation: favour hepatics Pro tip: More swelling: favour diuretics Feeling of cold in the joints: use cayenne internally and topically Devil’s Claw  Botanicals in Joint Pain FEATURED HERBS IN THIS SECTION Curcuma longa (Turmeric) Glycyrrhiza glabra (Licorice) Harpagophytum procumbens (Devil’s claw) Bupleurum sinensis (Bupleurum) Boswellia serrata (Frankincense) Capsicum annua (Cayenne) Polygonum cuspidatum (Japanese knotweed) Cannabis indica (cannabis) CASE PRESENTATION - Osteoarthritis A 63-year-old male presents with a worsening knee pain, aggravated after activity or long periods of walking. OUTCOME MEASURES Increase pain-free range of motion RELEVANT BOTANICAL ACTIONS TO CONSIDER PRIMARY SECONDARY or OTHERS TO CONSIDER SUPPORTIVE Anti-inflammatory Hepatic Analgesic Alterative Diuretic Adaptogen Circulatory tonic  Botanicals in Joint Pain Frankincense FEATURED HERBS BY BOTANICAL ACTION Actions Herbs Alterative Diuretic Hepatic (Hepatic or Diuretic) Nettle leaf (Urtica dioica folia) Polygonum cuspidatum Dandelion leaf (Taraxacum (Japaneses knotweed) officinale) Berberis vulgaris (Barberry) Yarrow (Achillea millefolium) Bupleurum sinensis (Bupleurum) Glycyrrhiza glabra (Licorice) Anti-inflammatory Turmeric (Curcuma longa) Actea racemose (Black cohosh) Devil’s claw (Harpagophytum Polygonum cuspidatum procumbens) (Japaneses knotweed) Frankincense (Boswellia serrata) Polygonatum biflorum  Botanicals in Joint Pain Cat’s claw (Uncaria tomentosa) (Solomon’s seal) Analgesic Kava kava (Piper methysticum) Valerian (Valeriana officinalis) Cannabis (Cannabis indica) Jamaican dogwood (Piscidia Cayenne (Capsicum annua) piscipula), Wild lettuce (Lactuca virosa) Adaptogen Ganoderma spp. (Reishi, Ling Codonopsis pilosula (Dan shen) zhi) Astragalus membranaceus Innonotus obliqus (Chaga) (Huang qi) Cordyceps sinensis (Cordyceps) 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, This formula should be well tolerated. Ginkgo may cause mild Contraindications stomach discomfort and, occasionally, headaches. and Potential Side Effects Relevant Herb-Drug Turmeric (Curcuma longa) will inhibit or induce certain pathways of Interactions cytochrome P450 metabolism  Botanicals in Joint Pain Other Effective Contrasting hydrotherapy is immensely beneficial in treating all forms Therapies of progressive arthritic conditions and for injury rehabilitation. Inclusion of healthy fats and oils, and ensuring appropriate amounts of protein are beneficial. Bone broths to promote macro and micro nutritional requirements Acupuncture for symptomatic relief Topical and local treatments like a cayenne salve or essential oils of eucalyptus, mint, and wintergreen for acute pain relief Consider use of Cannabis for symptomatic pain management TCM INTEGRATION - OA Similar to the conventional assessment, OA is considered a case of degeneration. This means it is a condition that has taken form and progressed from the Qi level to the Blood level, or perhaps even to the level of Jing as the bones have become irreparably damaged. In most cases of OA, this will be a pattern of deficiency over time, characterized by the Qi and Blood failing to nourish the joints leading to degeneration. Fluids, responsible for nourishing and lubricating the joints are also likely deficient. Because the Liver controls tendons and sinews, a Liver Blood deficiency failing to nourish the tendons and sinews may underlie the pattern, and in many cases may be the primary etiological factor. Because the bones are involved, a failure of the Kidneys to manifest bones may play a role. OA will be diagnosed as a Bi (painful obstruction) syndrome. Most OA is considered Cold and Damp lodging in the joint due to deficiency of Yang or Blood. Where there is Blood stasis, this stasis may transform into Heat that results in the inflammation commonly see in OA.  Botanicals in Joint Pain CASE PRESENTATION – Rheumatoid Arthritis A 32-year-old female presents with worsening pain in her hands and knees that impairs activity. The pain is worse in the morning and improves as she starts to move. Blood tests confirm rheumatoid factor (RF) positive, and there is a family history of rheumatoid arthritis. OUTCOME MEASURES Improve pain in joints Prevent progression to physical degeneration RELEVANT BOTANICAL ACTIONS TO CONSIDER PRIMARY SECONDARY OTHERS TO CONSIDER Hepatic Diuretic Analgesic Anti-inflammatory Laxative  Botanicals in Joint Pain Licorice root FEATURED HERBS BY BOTANICAL ACTION Actions Herbs Hepatic Chai hu (Buplereum sinensis) Goldenthread (Coptis sinensis) Barberry (Berberis vulgaris) Licorice root (Glycyrrhiza glabra) Burdock (Actium lappa) Dandelion root (Taraxacum off.) Yellow dock (Rumex crispus) Andrographis (Andrographis St. John’s wort (Hypercium paniculata) perforatum) Polygonum cuspidatum (Japaneses knotweed) Anti-inflammatory Turmeric (Curcuma longa) Actea racemose (Black cohosh) Devil’s claw (Harpagophytum Polygonum cuspidatum procumbens) (Japaneses knotweed) Frankincense (Boswellia serrata) Polygonatum biflorum  Botanicals in Joint Pain Cat’s claw (Uncaria tomentosa) (Solomon’s seal) Analgesic Kava kava (Piper methysticum) Valerian (Valeriana officinalis) Cannabis (Cannabis indica) Jamaican dogwood (Piscidia Cayenne (Capsicum annua) piscipula), Wild lettuce (Lactuca virosa) HERB SELECTION Formula Bupleurum sinesis 40 Glycyrrhiza glabra 30 Hypericum perforatum 30 100 Dosage As tincture: 1 tbsp bid between meals Cautions, SJW is generally contraindicated whenever patients are taking other Contraindications medications and Potential Side Licorice may raise blood pressure if used for more than two weeks. Effects Relevant Herb-Drug SJW induces CYP 450 3A4. As such, it should not be used Interactions concurrently with any medications. Specifically, it should never be used with SSRIs or anti-psychotic medications. Other Effective In any autoimmune condition, it is essential to identify and avoid Therapies triggers. Contrast hydrotherapy treatments. Acupuncture may be effective in treating RA, both by reducing acute pain and decreasing inflammation.  Botanicals in Joint Pain TCM INTEGRATION RA is generally considered a pattern of Heat, usually Damp Heat affecting the joints, or sometimes Hot Phlegm lodging in the joints. In general, where there is pain, this is often referred to as Bi syndrome, and in RA it is often considered Heat Bi. Treatment principles are clear heat (RA is generally an excess heat pattern), and nourish Qi of the Kidneys (controls bones, governs fluids) and Liver (controls tendons, promotes smooth flow of Qi and blood).  Botanicals in Joint Pain SELECTED MONOGRAPHS Bupleureum chinensis (Chai hu) Primary Actions: Hepatic, alterative, anti-inflammatory, hepatoprotective Constituents: Triterpene saponins, sterols, volatile oils, polysaccharides Indications: Hepatic congestion, arthritis, chronic inflammation, acute infections with fever Cautions/Contraindications: Avoided in cold conditions or constitutions. Safety rating during pregnancy and lactation not established. Extra Information: Excellent hepatic alterative for long-standing inflammation from physical or emotional accumulation. Useful in hepatitis as both a hepatoprotective and an anti- inflammatory. Part Used: Root Daily Therapeutic Dose Tincture: 6–12 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 3–12 g Pairs Well With: Berberis vulgaris, Uncaria tomentosa, and Harpagophytum procumbens for inflammation, especially of joints. Paeonia alba for stagnant menses with heat presentation. Closest Substitute: Baptisia tinctoria Boswellia serrata (Frankincense) Primary Actions: Antimicrobial, anti-inflammatory, astringent Constituents: Resins, boswellic acid, volatile oils Indications: Inflammatory joint conditions, IBD, topical antimicrobial Cautions/Contraindications: Considered safe, though not generally taken internally in large amounts. Extra Information: To be effectively extracted, boswellia is dissolved in 90% alcohol, making even small ingested doses a risk for intoxication. Potent and profound fragance used commonly as a fortifying and attractive essential oil. Reasonably good evidence exists to support the use of boswellia as an anti-inflammatory, particularly in the treatment of RA. Part Used: Resin Daily Therapeutic Dose Tincture: 2–4 mL (1:5 in 90%)  Botanicals in Joint Pain Daily Therapeutic Dose Infusion or Decoction: Best as powder or as encapsulated supplement. Suggested dose 300–3000 mg. Pairs Well With: Salvia officinalis as an antimicrobial for oropharyngeal and upper GI infections. Harpagophytum procumbens and Curcuma longa in formulas for inflammatory rheumatoid conditions. Closest Substitute: Commiphora myrrha 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/Contraindications: Non-toxic, but large doses will cause sweating and possible syncope. Safety rating during pregnancy and lactation not established. Extra Information: Acts as pain relief via local topical substance-P depletion. Excellent in salves for arthritis. Avoid contact with mucus membranes; internal use effective, but must be used in low doses. Part Used: Dried or powdered fruit Daily Therapeutic Dose Tincture: 1–5 mL (1:5 in 25%) Daily Therapeutic Dose Infusion or Decoction: 1–2 g powder (potency of starting material can vary considerably) Pairs Well With: Zanthoxylum americanum as warming circulatory tonic. Closest Substitute: Zingiber officinalis 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/Contraindications: Broadly considered safe though acts as a mild inhibitor of phase I and inducer of phase II liver conjugation and should therefore be used with mild caution in patients taking medications with narrow therapeutic index. In large doses of greater than 15 g per day (sometimes recommended in practice), turmeric may augment the effects of antiplatelet and anticoagulant medications. Preg A, Lact C.  Botanicals in Joint Pain Extra Information: Related to ginger, turmeric is warming and soothing to the stomach. May protect against NSAID-induced ulcers. Good-quality powder is likely the preferred method of delivery, and turmeric is best absorbed when taken with a meal containing fats or oils. Part Used: Root Daily Therapeutic Dose Tincture: 8–24 mL (1:5 in 30%) Daily Therapeutic Dose Infusion or Decoction: 8–20 g dried root or powder Pairs Well With: Dioscorea villosa for inflammation related to circulation Closest Substitute: Harpagophytum procumbens Ginkgo biloba (Ginkgo) Primary Actions: Circulatory tonic, vasodilator, anti-inflammatory, anticoagulant (as an antiplatelet activator factor [PAF]) nootropic, mild astringent. Constituents: Flavonoid glycosides, terpene lactones (gingkolides) Indications: Poor perfusion of tissues, especially cerebral; inflammation, clot formation, cognitive decline, erectile dysfunction, BPH. Cautions/Contraindications: Though not toxic, may cause stomach discomfort or cramping. Preg B, Lact CC. Extra Information: At 200 million years old, Gingko trees are the most ancient species of tree on the planet and the only remaining member of their genus. They are also thought to be the hardiest tree species and are among the most resilient trees in urban environments. Gingko trees have a distinct male and female. The females produce a characteristically unpleasant smelling but edible fruit. Part Used: Leaf and fruit Daily Therapeutic Dose Tincture: 3–9 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 4–10 g dried leaf Pairs Well With: Actaea racemosa and Hydrastis canadensis for vertigo. Capsicum frutescens in formulas for improved circulation. Centella asiatica for enhancing cognitive performance. Closest Substitute: Centella asiatica Glycyrrhiza glabra (Licorice)  Botanicals in Joint Pain Primary Actions: Adaptogen, particularly to the adrenals; anti-inflammatory, demulcent, antiviral, hypertensive Constituents: Triterpene saponins (glycyrrhizin), glycyrrhetinic acid, chalcones Indications: Ongoing stress, hypotension, asthma, eczema, chronic or acute bronchitis, emphysema, URTI, post-viral cough, stomach ulcers (mostly DGL) Cautions/Contraindications: CI in hypertension. Preg A, Lact C. Extra Information: Licorice acts primarily as an aldosterone-like endocrine modulator. Thought of as specific to cases of deficiency presenting with dizziness and hypotension. Excellent in URTI as an antiviral and demulcent. Excellent for lingering post-viral cough. In TCM, one of two herbs that enter all 12 meridians. Glycyrrhiza uralensis mostly used in TCM, properties considered interchangeable. Part Used: Root Daily Therapeutic Dose Tincture: 3–9 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 2–9 g dried root Pairs Well With: Rosmarinus officinalis for coughs, especially viral coughs. Bupleurum sinensis in anti-inflammatory combos where clearance by the liver is suboptimal. Hypericum perforatum and Melissa officinalis (as infused oil) for the topical treatment of herpes infections. Closest Substitute: None Harpagophytum procumbens (Devil’s claw) Primary Actions: Anti-inflammatory, antirheumatic, mild anodyne, hepatic Constituents: Iridoid glycosides (harpagoside), phenolic acids, quinone Indications: RA, other inflammatory conditions, other arthritic conditions Cautions/Contraindications: Considered safe, though research inconclusive. Preg B, Lact C. Extra Information: Specific as an anti-inflammatory for rheumatic pain. Part Used: Root Daily Therapeutic Dose Tincture: 3–6 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 4–12 g dried root Pairs Well With: Curcuma longa as a rheumatic anti-inflammatory Closest Substitute: Curcuma longa  Botanicals in Joint Pain Hypericum perforatum (St. John’s wort) Primary Actions: Uplifting nervine, antiviral, anti-inflammatory, vulnerary Constituents: Volatile oils, hyperforin, naphthodianthones (hypericin), flavonoids Indications: Mood dysregulation, neuralgia, anxiety, viral infections Cautions/Contraindications: Sensitization may occur at higher doses of the herb or its extract. Induces CYP3A4, thus potential drug interactions with numerous substances. Serotonin syndrome possible when taken in combo with SSRIs. Photosensitivity may occur in some indivduals. Preg B, Lact CC. Extra Information: Excellent as topical oil for herpes lesions. Considered by some a specific for irritability and anxiety from menopausal changes. Part Used: Aerial parts Daily Therapeutic Dose Tincture: 2–10 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 2–4 g Pairs Well With: Calendula officinalis and Stachys betonica for depressive states, especially Seasonal Affective Disorder. Glycyrrhiza glabra and Melissa officinalis as a topical for herpes lesions. Closest Substitute: None Polygonum cuspidatum (Japanese Knotweed) Primary Actions: Anti-inflammatory, hepatic, anti-microbial, laxative, astringent, anti-oxidant Constituents: anthraquinone glycosides, tannins, resveratrol Indications: Any joint pain. Inflammatory and auto-immune conditions: RA, psoriasis, lupus. Hepatitis, stagnant menses, fibroids, endometriosis. Any condition of difficult urination. Lyme. Cautions/Contraindications: Acts as a stimulating laxative. Do not use in pregnancy. May cause nausea or stomach pain. Extra Information: Also known as Reynoutria japonica, Fallopia japonica and Hu zhang. Bitter and cold in nature, Knotweed can be thought of as specific for any conditions characterized by pain, inflammation, and obstruction. Part Used: Root Daily Therapeutic Dose Tincture: 6–12 mL (1:5 in 40%) Daily Therapeutic Dose Infusion or Decoction: 9–15 g dried herb Pairs Well With: Polgonatum biflorum for joint pain. Closest Substitute: Rumex crispus