Not patches, cures for arthritis pain:
In my opinion, when I discuss cures for arthritis pain, those “cures” need to last a minimum of 6 months. It takes time to do something to improve the joint space cushioning fluid (hyaluronic acid) or the amount of cartilage in the joints. I will present every single possible way to potentially cure arthritis pain, leaving medical drug therapies and natural therapies for other articles to come.
What follows is a summary of everything available as potential cures for arthritis pain. I will include my recommendations, both pro and con, for each. I am using the term “arthritis” to refer to the most common type of arthritis – osteoarthritis or “degenerative arthritis.” The other types of arthritis and all statistics are in the previous link.
Prolotherapy is an injection of an irritant solution (often dextrose, a form of sugar) into joints, ligaments, and tendons. A typical treatment program involves 15 to 20 shots given monthly for three to four months, followed by occasional, as-needed shots. I’m telling you about this because this is a comprehensive tell-all article.
While (you’re not going to believe this one!) the therapy has been in use for 75 years, researchers still aren’t sure how it improves pain and other symptoms. Many are skeptical it even works at all. A leading theory is injecting dextrose at certain concentrations triggers a natural healing process, stimulating repair of damaged tissues.
What do studies look like for this?
In one promising randomized controlled trial, 90 people with knee arthritis or “OA” were placed into one of three groups. The first group received prolotherapy, the second received inactive salt-water shots and the third was given a pamphlet of knee exercises to be done at home three times a week.
For the first two groups, doctors injected a solution into the knee joint and in up to 15 surrounding tender areas targeting points of pain and swelling. This procedure was performed on three occasions, four weeks apart (with the possibility of two extra treatments, if needed). The study was “blinded,” meaning no one involved knew who got prolotherapy sugar-water versus salt-water injections.
The researchers used what’s known as a WOMAC score to compare participants’ levels of pain, stiffness, and physical function before treatment and after they received their first series of shots or started the exercise program.
The WOMAC score of those who received prolotherapy improved 24 percent, compared with an 11-percent improvement in the salt-water group and a 12-percent improvement in the exercise group. The changes in the prolotherapy group versus the comparison groups were great enough that researchers could rule out the possibility of chance findings. More importantly, the changes were large enough to make meaningful differences in patients’ daily lives.
Other research on prolotherapy for knee OA shows benefits.
A small trial of 13 patients with thumb or finger OA published in the Journal of Alternative and Complementary Medicine in 2000 compared the injection of a mixture of dextrose and lidocaine (a pain reliever) with lidocaine alone. Researchers found that patients who received the dextrose combo injections had less pain when moving their fingers compared with those who got only lidocaine.
A trial of 38 knee OA patients published in 2000 in Alternative Therapies in Health and Medicine also compared dextrose plus lidocaine with lidocaine alone. This study showed that the people who got dextrose had substantially better outcomes than their lidocaine-only counterparts regarding pain, swelling, knee buckling and knee flexibility.
Doubts of efficacy:
Few Rheumatologists offer this therapy. They cite (and I’ll say they have a point here) that there is a paucity of studies. There is also some concern that perhaps injecting dextrose into joints will cause harm.
Injecting dextrose into the joint might cause a buildup of damaging sugar molecules in joint tissues. These molecules are similar to those that form in people with diabetes, according to some. It’s also not known what sugar could do to the composition of synovial fluid (the fluid that lubricates and lines our joints). Changing its composition could be harmful to cells it comes into contact with.
Some practitioners of prolotherapy say it works for their patients and that others don’t do it (likely) because it is so inexpensive compared to the treatments. I’ll talk about in a moment. I really don’t have a good feeling about this. More so, I am uncomfortable with the little amount of research on this. When someone asks if this is a real cure for arthritis, I give this a big NO. I like the idea of doing anything we can to restore cartilage. At the very least, try to improve hyaluronic acid lubrication of joints which leads me to our next topic.
Hyaluronic acid injections for osteoarthritis:
In a healthy joint, a thick substance called synovial fluid provides lubrication, allowing bones to glide smoothly against one another. Synovial fluid acts as a shock absorber, as well. In people with osteoarthritis, a loss of hyaluronic acid, a critical substance in synovial fluid, occurs over time. This appears to contribute to joint pain and stiffness.
That led researchers to ask if replacing hyaluronic acid would relieve osteoarthritis symptoms and be one of the cures for arthritis pain. The most common treatment of osteoarthritis of the knee is hyaluronic acid injection, but it aids other joints too, such as the hip and ankle.
While studies of hyaluronic acid injections occasionally yield disappointing results, many doctors who treat osteoarthritis say that the weight of scientific evidence – and their own clinical experience – suggests that a shot in the knee can produce significant relief for some patients. In addition, clinical research hints that hyaluronic acid may do much more than simply re-oil a creaky joint.
As I was saying, hyaluronic acid has a lot of other activities in the joint. For example, research suggests that hyaluronic acid interferes with prostaglandins and cytokines, naturally occurring compounds that promote inflammation. What’s more, studies indicate that injecting supplemental hyaluronic acid may coax the joint into increasing its own production of this important substance. This could, in turn, help to preserve cartilage and slow the progression of the disease.
Is this a reasonable alternative to NSAIDs?
Hyalgan was approved FDA in 1997. There are now five hyaluronic acid treatments approved for knee osteoarthritis used in this country. Again, doctors are free to use it “off-label” on other joints. Hyalgan, along with Orthovisc, Supartz and Synvisc are made from rooster or chicken combs. Euflexxa comes from bacteria.
Hyaluronic acid injections are one treatment option doctors may offer when a patient is no longer able to control osteoarthritis pain with ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDs), or the patient can’t tolerate these drugs due to side effects. The treatment regimen for hyaluronic acid usually involves receiving one injection in the affected joint per week for three to five weeks. Many patients appear to get at least some relief – eventually. If I can add my two cents I feel that NSAIDs and Acetaminophen are so potentially toxic that I recommend this and other treatments (to follow) even prior to just recommending “drugs.” An initial treatment regimen can be “all natural” as I will discuss in another article, but I personally nix the idea of daily “drugs” for pain if avoidable.
The research on pain control:
In 2006, a team led by Nicholas Bellamy, MD, of the University of Queensland in Brisbane, Australia, reviewed 76 studies examining the use of hyaluronic acid for treating knee osteoarthritis. This review is the largest review paper written on the use of hyaluronic acid for osteoarthritis of the knee.
Conclusions were that pain levels in the average patient who receives these injections are reduced by 28 to 54 percent. That’s roughly what a patient might expect from taking NSAIDs, the authors concluded.
Meanwhile, hyaluronic acid improved the ability to move about and perform daily activities by 9 to 32 percent.
As a patient soon learns, though, hyaluronic acid is no quick fix. According to Bellamy’s review, it takes about five weeks, before a patient experiences the full benefits of hyaluronic acid. This review found that pain-relieving benefits of hyaluronic acid persist at peak levels for an average of about three months. Some physicians give patients a double shot in the knee, one injection each of hyaluronic acid and corticosteroids, for quick-acting and long-lasting relief. A footnote on steroid injections: more than 3x/year will erode cartilage.
About 30 percent of people who undergo hyaluronic acid injections become virtually pain-free and symptom relief may last up to two years. Yet, another 20 percent of patients experience no benefit. Unfortunately, there is just plain no way to predict a stellar versus no response.
However, hyaluronic acid isn’t universally lauded or even approved. In June 2013, the American Academy of Orthopedic Surgeons (AAOS) issued a new set of recommendations for the treatment of knee OA.
Based on a review of 14 studies, the organization determined hyaluronic acid did not meet the minimum clinically important improvement measures, according to David S. Jevsevar, MD, chair of the evidence-based practice committee for the AAOS. (And am I the only one to ask here if the profit from joint replacement had anything whatsoever to do with this?)
With five brands available in the United States, your next question is likely which one is the most effective, right?
There have been very few head-to-head comparisons of the various products in clinical trials. Many Orthopedists interviewed pretty much agree they all work about the same. Likewise, the risk of side effects is similar among the different products. The most common side effect is pain and swelling at the injection site that fades within a few days. The take-away is that this is worth trying, but I’d add in one of the other modalities discussed below AND would look at the contents of our arthritis pain relief kit in a link at the end of this article.
PRP (Platelet-rich-plasma) injections for osteoarthritis:
What is it?
PRP is in a patient’s blood. It delivers a high concentration of growth factors via platelets to arthritic cartilage that can potentially enhance healing.
You basically take a person’s blood, spin it down, concentrate the platelets, and inject a person’s knee with their own platelets in a concentrated form. This then activates growth factors and stem cells to help repair the tissue, calm osteoarthritis symptoms and decrease inflammation.
Let’s discuss the studies:
A study published in the Clinical Journal of Sports Medicine has shown that platelet-rich plasma (PRP) holds great promise for treating patients with knee osteoarthritis. The treatment improved pain and function, and in up to 73% of patients, appeared to delay the progression of osteoarthritis. And it gets better-
In this study, researchers at The Hospital for Special Surgery enrolled patients with early osteoarthritis, gave them each an injection of PRP (6-ml), and then monitored them for one year.
Fifteen patients underwent clinical assessments at baseline, one week, and one, three, six, and 12 months.
At these time points, Physicians used the same criteria to assess overall knee pain, stiffness, and function, as well as a patient’s ability to perform various activities of daily living.
At baseline and then one year after the PRP injection, physicians also evaluated the knee cartilage with magnetic resonance imaging (MRI), something that had not previously been done by researchers in other PRP studies. The radiologists reading the MRIs did not know whether the examination was performed before or after the PRP treatment.
While previous studies have shown that patients with osteoarthritis can lose roughly five percent of knee cartilage per year, the HSS investigators found that a large majority of patients in their study had no further cartilage loss. In at least 73% of these cases, there was no progression of arthritis in any of the three main compartments at the one year mark. That is very significant, because long-term studies suggest a four to six percent progression of arthritis after one year.
Stem Cell Therapy-what is it and what isn’t it?
Stem cells come from the patient. Mesenchymal stem cells are in bone marrow, fat, and other tissues. With proper use, they are responsible for rebuilding and regenerating the body. The stem cells cannot work alone. They require help from growth and support factors from other tissues and blood.
The right anti-inflammatory cytokine secreting stem cells help the body renew and heal itself. Mesenchymal stem cells have the ability to signal other mesenchymal cells to proliferate. In the context of arthritis, they signal chondroblasts to form new chondrocytes and thus increase the cartilage in the joint. The stem cells don’t universally “turn into” a new cell which is what many widely believe. However, they can differentiate into other mesenchymal cells. For example, cartilage.
What is so promising is stem cells may have the potential to prevent a knee, hip, shoulder or ankle replacement. Stem cells may also help repair a torn rotator cuff or labrum, and heal a meniscus tear of the knee. Our body possesses the power of repair in our stem cells. However, they need to be concentrated in an area of injury or chronic degeneration to be effective.
Stem cell injections for osteoarthritis
Doctors doing stem cell injections note fat, and bone marrow mesenchymal stem cells have a very good potential for articular cartilage regeneration.
Stem cell injections for osteoarthritis can help maintain healthy tissues by acting as repair cells or to reduce inflammation. The injection of mesenchymal stem cells has produced promising outcomes in pre-clinical models of joint disease.
What preliminary research is confirming is that stem cell therapies have shown quite encouraging results.
The area of injury or arthritis is treatable with both stem cells and platelet rich plasma (PRP). If stem cells are the seeds, then PRP is considered to be the fertilizer.
PRP, a combination of growth factors and platelets naturally found in the body, provides cell signals and nourishment to help the stem cells flourish and develop into new joints, ligaments, tendons, and cartilage.
PRP not only triggers stem cell development but can also help stem cells regenerate on their own inside the body. It can also attract circulating stem cells to the area of injury.
Most cases of stem cell and PRP treatments are successful. The treatments avoid the pain, disability, downtime, and risk associated with major surgery. There is minimal recovery from a stem cell or PRP treatment- usually just a little soreness and bruising in the particular area.
There are no reports of serious adverse effects in scientific literature when adult mesenchymal stem cells are used in these procedures. Afterward, the patient is encouraged to use the joint normally. Follow up treatments of PRP are given in monthly intervals to continue to allow the stem cells to do their work. Since stem cell treatment is very safe, it can be repeated in the joint if necessary to obtain optimal results.
MRI studies with stem cells +PRP are quite promising, showing an actual amplification of cartilage volume. Note that there is no increase in cartilage with PRP alone, just a stabilization. However, the combo shows an actual increase. I obviously show a bias towards the “combo” approach, supplementing pain relief with natural products which help stimulate cartilage as well.
Human growth hormone
Unfortunately, the FDA keeps a very tight rein on the indications for usage of this hormone, which starts “going down” when we hit 30. To conceptualize how it works, think about how quickly you healed from a sprained ankle or gash when you were a kid as compared to now. That’s due to HGH-human growth hormone.
It stimulates growth and cell reproduction and regeneration. It is a 191-amino acid, single-chain poly-peptide hormone that is synthesized, stored, and secreted by the pituitary gland.
Growth hormone is used clinically to treat children’s growth disorders. It was also fleetingly allowed by the FDA to treat adult growth hormone deficiency. But now, the FDA disallows Adult HGH deficiency as a diagnosis so many who could benefit cannot.
The benefits of HGH are numerous. People have a decrease in body fat, an increase in muscle mass, increased bone density, increased energy levels, improved skin tone, and texture, increased sexual function and improved immune system function.
And research shows it to increase cartilage in joints.
This effect is noticeable with daily sub-q injections. Recent studies show an increase in knee cartilage when the injection is directly into cartilage-lacking knee joints. These studies have been largely suppressed, especially by the orthopedic community. I’m just going to say “hmmm” and leave it at that for the moment.
But how does human growth hormone help in arthritis?
1. HGH directly stimulates division and multiplication of chondrocytes of cartilage. When you thicken cartilage, you improve “joint cushioning.”
2. HGH stimulates production of insulin-like growth factor 1 (IGF-1) which has growth-stimulating effects on a wide variety of tissues. IGF-1 has stimulatory effects on bone and cartilage cells to promote growth.
3. HGH stimulates the growth (hypertrophy) of muscle thus improving the “joint cushioning” effect. It’s also sometimes great for muscle soreness relief associated with arthritis, chronic back pain and more.
4. In terms of arthritis, human growth hormone is seen to have a powerful anti-inflammatory effect. It can produce pain relief that can last up to several months.
I’ll say this again for emphasis. Not only are there are studies on HGH as a “systemic injection,” but also on HGH injection into knees showing MRI proof of new cartilage. However, the FDA prevents this use. I find this quite shocking and saddening. I also have my theories as to “why this is.”
It is evident to me as it is to you (right?) that ideally, you’d get injections of PRP+stem cells+HGH with systemic HGH administration for optimal results if the FDA said “OK” to all of that.
Since this potent and effective substance doesn’t have approval nor is legally available for use in the U.S., I won’t dwell long. I will give you enough information in case you wish to explore out-of-the-country options.
IGF1LR3 is a research drug; the FDA did not give approval yet. It is currently under research for nerve tissue repair, possible burn victims, and as a possible aid in muscle wasting for AIDS patients.
Perhaps the most interesting and potent effect IGF1R3 has on the human body is its ability to cause cellular hyperplasia. This is the actual splitting of cells. To illustrate, Hypertrophy is what occurs during weight training and your own HGH stimulates muscle-pumping IGF1 production.
With IGF1LR3 use you are able to cause muscular hyperplasia which actually increases the number of muscle cells present in the tissue. Couple this with weight training and you are able to mature these new cells. There is a bit of a controversy about the physiology of this but we do see more muscle “motor units” emerge. So IGF1LR3 can actually change your genetic capabilities in terms of muscle tissue and cell count.
Obviously, use of this peptide would greatly enhance muscular joint cushioning. Research may very well bear out that it enhances cartilage growth as well.
Last resort: Joint replacement for severe, painful arthritis:
In the past several years, there has been an enormous increase in the amount of joint replacements. Many industries profit-from those that sell metals to the manufacturers, to the manufacturers of the artificial joints and more. What more? Think about all the competing joint replacement companies who have “device reps”. They go into the operating rooms with Orthopedists to instruct them. These reps are paid handsomely, more than a manger, making $163,468 per year!
Now then throw in what an Orthopedist makes for a living, with the bulk of it stemming from joint implants. Then we have hospitals, rehab hospitals, Physical Therapy Clinics and we have a real ‘industry here’, don’t we? Despite, my obvious bias against this, I WILL say that in some cases this is absolutely indicated.
Joint replacement is indicated when someone has lost a lot of cartilage, is told they have “bone on bone” and cannot afford the therapies I just talked about. Insurance companies pay handsomely for joint replacements but not all too well for any of the therapies listed above. Certainly, I do not wish for these people to be in pain. For them, what is not reimbursable by insurance is what I hope becomes affordable. In defense of the implants themselves, unlike the first implants, the current ones are made of titanium. Hence, one of the reasons for the high cost. Also, instead of the “glue” only lasting several years, now they can last (80-85% chance) up to 20 years.
Use diet, exercise and (non-drug) arthritis integrative treatments as your first measures. Hyaluronic acid might be helpful. The best semi-standard quasi-cure if I can say it like that currently appears to be stem cells plus PRP.
Update 2018: The peptide BPC-157, with our without human growth hormone also injected is being studied for cartilage regeneration. The results are not ‘in” but it’s something to watch.