Natural Arthritis remedies: Boswellia

Boswellia, also known as Indian Frankincense, is a traditional ayurvedic medicine that has been used for all sorts of conditions from coughs and sores to snakebites and colic, and of course, it has also been used as treatment for arthritis pain, as well. But does it really work? And is there any basis for it working at all?

Generally speaking, these are the critical questions that you must always ask when you are considering taking supplements, like Boswellia, along with added questions of safety and interactions with any current medications/medical conditions that you may be taking, so it's important to always consult with your physician.

It appears that in the case of Boswellia, the answer seems to be that it may in fact, be helpful to some degree with alleviation arthritis pain, even though unlike most arthritis treatments (like NSAIDS for instance, Boswella is neither an anti-pyretic (helps reduce fever) or an analgesic (helps reduce pain topically like a mentholated cream).

Boswellic acid, which is the major constituent, seems to have an anti-inflammatory effect, inhibiting the production of several inflammatory cytokines such as NF-KB and TNF-alpha, which are powerful cytokines that can produce fever, cell death, and sepsis. Likewise, Boswella may help reduce the production of inflammatory molecules called eicosinoids by inhibiting enzyme called 5-lipoxygenase. This may help relieve the pain of osteoarthritis, (1) as eiconosoids modification can be helpful in lessening the pain from arthritis. This is what Omega-3 fatty acids are thought to do, that is they help modify the eiconsoids metabolism/milieu so it is more generally anti-inflammatory.

Still, some skepticism should be applied, if not liberally, as other studies have been less enthusiastic in proclaiming a pain relieving effect. (2) In this study, ASU's (which are derived from soybean and avocado oil) have been shown to be much more effective in the treatment of arthritis pain, which is what I typically recommend for most patients, along with several other supplements and dietary strategies, to help attempt to naturally relieve some of the symptoms of arthritis.

Is Boswella then right for you? Hard to say, really. Although it does not appear to be harmful, it may not be all that helpful compared to some of the other more well known and well-studied supplements available, such as chondroitin, MSM, and glucosamine.  That being said, it may be worthwhile to consider this supplement (under your doctor's supervision is always preferable) if these other more well known supplements fail to help relieve the pain you have.

References: 

Sengupta K, Alluri KV, Satish AR, et al. A double blind, randomized, placebo controlled study of the efficacy and safety of 5-Loxin(R) for treatment of osteoarthritis of the knee. Arthritis Res Ther. Jul 30 2008;10(4):R85.

Chrubasik JE, Roufogalis BD, Chrubasik S. Evidence of effectiveness of herbal antiinflammatory drugs in the treatment of painful osteoarthritis and chronic low back pain. Phytother Res. Jul 2007;21(7):675-683.

Supplements for arthritis

If you have pain, especially in your hands, and you have been told it's not carpal tunnel syndrome, but rather what you have is arthritis, there are several things that you can do. If it's really bad, surgery is an option. If it's only moderately bad, then a steroid injection can help, but if you are like the majority of patients that I see on a daily basis, then you are neither a candidate for surgery or steroids. 

Most doctors will then put you in the 'not much to do right now' category, and see you when the condition gets worse. But the fact is, when you have pain, most people would like to do something before it actually gets worse, and one of the roads that I recommend to patients is supplements. 

Now, I always say, supplements are only one aspect, that is, one road to take. The others are things like exercise, diet, and ergonomic modfications, but the fact is, supplements do help, and they can help a lot. 

I have written about this before in my other blog, but the information is constantly changing, as new products are coming out and new scientific knowledge is being discovered. 

Here is a update:

The most well known supplements today are:

1. Glucosamine is a supplement which is thought to decrease inflammation in the articular cartilage (the cartilage of joints that move, or articulate, like your knee and thumb, for instance) and it also seems to help prevent degradation of the articular cartilage. Glucosamine is a pre-cursor to molecules known as  glycosaminoglycans, which are part protein and part sugar molecule. GAG's are also known as mucopolysaccharides, and  they are important to joint health because they provide both the lubricating fluid and the cushioning aspect of the joint itself. If you think of it in terms of a car, it's like having the oil for your pistons and shock-absorbers. Studies have shown that Glucosamine appears to effective in helping treat osteoarthritis, and as a result, it is still a popular supplement which I recommend to all of my patients. 
2. Chondroitin sulfate is also a GAG, but it contains sulfur in its structure, which makes it unique. Sulfur is a very important micronutrient for a wide variety of procesess in the body, and it can help a great deal in relieving joint pain. (I have written about it before) In fact, many spa and mineral springs that have been in use for hundreds (and sometimes thousands) of years, have very high sulfur content in their water, suggesting that although the ancients may have not known the exact process by which they were deriving benefits from mineral springs, they were certainly observing results, which is probably one of the reasons why they were (and are in many cases, still) so popular. Chondroitin sulfate is thought to reduce some of the expression of anti-inflammatory substances within the joint thereby relieving joint pain.
3. A combination of glucosamine and chondroitin sulfate.  Although I discussed each of these supplements separately, it is important to note that these supplements are often sold together in combination, and this is because the combination is thought to work synergistically to help alleviate joint pain.
4. A special 'supplement' that deserves mention within this blog is hyaluronic acid, which like Glucosamine and Chondrotion sulfate which can be taken in supplement form, but now is more commonly given alone in the form a joint injection called Synvisc (but there are many other similar brands available). I give Synvisc injections for thumb arthritis pain quite frequently, but it is important to note that since this drug is still under patent, and can be rather expensive. You want to make sure that your insurance plan covers it, and if not, then you can often negotiate a payment plan with affordable rates with your doctor. 
5. Omega 3 fatty acids are essential fatty acids (mostly obtained from fish sources) which are important for a wide variety of function within the body, especially in the development and maintenance and health of neural tissue, but they also help a great deal with joint pain, as they tend to be anti-inflammatory.  Krill oil supplements  appear to be exceptionally helpful for joint pain when combined with hyaluronic acid, as they contain a natural anti-oxidant called astaxanthin, which helps prevent the Omega-3 fatty acids from going rancid, which they frequently do, if they are cheap or not used within a reasonable time frame. Likewise, astaxanthin may have some significant benefits as an anti-oxidant in itself. In either cases, krill oil may be a better choice when choosing Omega-3 supplements, and can help reduce chronic inflammation and joint pain.
6. A relatively new supplement called ASU, has become very popular over the last several years, and has been shown to help alleviate joint very effrectively for many people. ASU stands for avocado and soybean unsaponifiable fractions. It works in many of the same ways that glucosamine and chondroitin do, and can be added to glucosamine and chondroitin to help reduce pain. In regards to its overall safety, in 2002, the Cochrane Review, an independent health organization based in Oxford, England, examined herbal therapies for OA and found conclusive evidence concerning ASU. Specifically, a 2003 study published in the Journal of Rheumatology reported ASU inhibited not only the breakdown of cartilage but also promoted repair within the joint. The French government has tracked ASU’s safety record for more than 15 years and has yet to find any significant problems. 

Should I get a Steroid Injection for Carpal Tunnel Syndrome?

This is a question that I get asked quite often and it is not always an easy one to answer because there is context and contingencies that need to be addressed before any answer can be given definitively. 

 First, a little bit about steroid injections.  Giving the steroid is a standard nonsurgical treatment for carpal tunnel syndrome, and it is usually well tolerated, even though for some people it can be somewhat painful.

Several different types of steroids can be used for the injection.  They vary in their potency as well as their chemical nature, but essentially, for practical purposes, they are all just about the same.  

I like to use one called Celestone (the generic name as betamethasone), but other surgeons like to use different steroids such as Depo-Medrol or Kenalog. 

If a person has carpal tunnel syndrome and does not necessarily want surgery and conservative measures like night splinting, physical therapy,  massage and over-the-counter medications have not helped then a person can become a candidate for a steroid injection. 

The steroid is mixed with lidocaine, a numbing agent, and then injected into the carpal tunnel in order to help reduce swelling among the tendons that might be swollen as well as the nerve itself. 

It is very important to get someone who understands the anatomy very clearly to give you a steroid injection.  The fact of the matter is that steroid injections are not 'intuitive' and 'easily done' with little or no training.  They take a particular understanding of the anatomy, as well as specific instructions which are given to the patient in order to avoid intra-neural injection. 

This means when the medicine is injected directly into the nerve rather than around the nerve. A person who has had inadvertant injection of medicine into the nerve can sustain a nerve injury which can be permanent requiring surgery and may disable them in the future.

Intra-neural injection is a very serious condition that I have seen a few times painfully only in my surgical career and I would like to see it no more; however, it does occur, especially in inexperienced hands.

Thankfully though, the more likely scenario is that somebody who is inexperienced with giving steroid injections will simply not know where to place the medication and may become a little bit 'chicken' and simply not give the medication in the correct place,  resulting in no relief of pain. 

I have patients that come to my office and say that the carpal tunnel injections did not work.  What is worse is that that the injection itself can be very painful, so the fact of the matter is they do not want another steroid injection because of the pain of the injection process itself.  This is understandable. 

Many times, I tell patients not to get a steroid injection and proceed directly to surgery because it is a definitive step in the properly selected patients and will relieve the pain in the majority (meaning 95% to 99%)  of  instances. 

But to make this decision you have to know your patient very well and know the anatomy very well and you have to understand if your conservative treatments are working or not. 

The fact of the matter is that the steroid injections are not permanent. At best they last two to three months and in fact 80% of same people who receive a steroid injection will have their symptoms return within a year and in my clinical practice that number is probably higher on the order of 90% to 95%.

In short, steroids are not a permanent solution, but they can delay the need for surgery especially if a patient wants to keep working for a little bit of time or has a personal/family issue that they would like to take care of before they undergo surgery. 

This is completely reasonable and is something that I see quite frequently because as a hand surgeon you simply do not treat the hand, you treat the person and as a doctor, you try to treat the whole person and take the big picture into account. 

I always stress in addition to all the standard conventional nonsurgical methods of treating carpal tunnel syndrome before considering surgery. 

 I stress on nutritional solutions which include proper diet, lifestyle and alternative forms of therapy such as yoga as well as specific supplementation that helps with the metabolism of nerves in general like the vitamins Coenzyme, Q10 omega 3, fatty acids, etc. 

I always try to look at the whole picture and although I am not against any of the conventional surgical methods of treating carpal tunnel syndrome, I do feel many long-term cures rest on the pillars of diet and lifestyle, that is you should always proceed with more invasive and risky procedures like carpal tunnel surgery or harsh medications or steroid injections only after you have tried the proper dietary and lifestyle interventions.  

Hand cancers.

Of all the nasty things that happen frequently to your hands from infections, fractures, dislocations, and arthritis, one thing does not occur that frequently--cancer.

Well, not exactly.

Cancer does occur in the hands and when it does, it's usually a very bad thing. The most common cause of cancer in the hand is a metastasis from someplace else on the body, eg lung cancer. This is a sign of a terminal condition, and in most cases, there is not much that can be done because the cancer is essentially incurable. Likewise, cancers that occur on the hand primarily (not a metastasis) are bad news too because they are usually things like sarcomas, which often require limb amputation and have a very poor prognosis.

Fortunately, these conditions do not occur frequently. In fact, the vast majority of tumors and masses in the hand are benign and are not cancer. But that doesn't mean cancer doesn't occur in the hands. It does, and quite frequently.

I am sure you are confused by now, and rightly so. How can cancer be both common and uncommon? Well, it's because the majority of cancers that occur on the hand are not hand cancers per se, but skin cancers that occur on the hand.

Semantics?

No, not really, because these cancers, which include things like basal cell and squamous cell carcinoma, occur throughout the skin of the body, and are treated essentially the same, ie with surgical excision in the vast majority of cases.

Plus, these cancers are, for the most part, indolent, meaning they are extremely slow growing and not aggressive, especially if they occur in older folks and are related to sun exposure. Likewise, they rarely metastasize and are not a cause of death in most people.

So, in short, they are not cancers you should be afraid of, but likewise, you shouldn't ignore them because they can grow and cause disfigurement, and if left long enough, they can metastasize. Some people do die from basal cell carcinoma, and this is a shame because it should never happen.

So what does a skin cancer on the hand look like?

Essentially, it is a red scaly lesion that may have a crust and quite often, bleed frequently. It may heal up between the times it gets crusty and bleeds and look shiny and waxy. Most importantly, these lesions do not go away, and over time, they do get bigger.

Here is a pretty classic example of a skin cancer (in this case, basal cell carcinoma) that has occurred on the hand. I can treat a cancer like this easily and safely with a small office procedure, and there is no need for any further treatment like chemotherapy and radiation. (Luckily, the vast majority of skin cancers that occur on the hand need no further treatment other than simple excision, which, as I have said, can be done in the comfort of my office.)

Below is an example of a squamous cell carcinoma. Now, although the majority of squamous call carcinomas on the hand are no big deal, left untreated they can cause much bigger problems than a basal cell carcinoma because they are more aggressive cancers. 

Generally speaking though, in a patient who is older where the cancer is the result of sun-exposure (and not say radiation or medications such as immune suppressants), squamous cell carcinoma is treated easily with excision only. But I can't stress enough that it is important NOT to let these things go neglected. They can easily get out of hand, rather quickly in some cases, and what should be a curable cancer, can become one that can result in an untimely and unnecessary death. 

So, make sure you see your doctor, and make sure if there is any doubt, get a biopsy, which can be a virtually painless, office procedure, that will give the answers that you need so you can get a reliable and effective cure.  

5 supplements/foods worth taking for hand pain/joint pain

I am a big fan of trying to find natural cures as I believe the human body, under the right circumstances, has almost an infinite capacity to heal itself. It's one of my basic philosophies of how I approach medicine.

I believe that, instead of  always trying to 'cure' a sickness when it presents itself, a doctor should also attempt to find a way to unleash the power of nature to help promote the cure (where the body can heal itself).

It's at the heart of preventive medicine, and it's also at the heart of the healing arts, which I am privileged to practice on a daily basis with patients. Unfortunately, that is simply not a big part of the current medical system. For instance, screening tests often are simply test that used to identify patients who then can undergo procedures. This is one of the reasons why about 80% of breast biopsies peformed in the United States today is negative for breast cancer. But this a complex issue, and I do not want to go 'off track' here.

It is important to note that I am not abandoning conventional Western medicine by saying this. As a hand surgeon, and I do believe that things like carpal tunnel surgery, in properly selected patients, is both an effective and reliable way to treat carpal tunnel pain. It is also exceptionally safe.

But the reality is that it doesn't work for everyone, and in fact, for many patients, when they undergo carpal tunnel surgery without effectively treating things like diabetes, obesity, and thyroid conditions by trying to find cures that focus on diet & lifestyle, are basically putting the 'cart before the horse' and sabotaging their chances for an effective and long lasting cure.

So, one of the things I stress in my practice, in addition to dietary & lifestyle interventions, is supplementation.  Supplementation is controversial among many medical experts, and rightly so. There are many claims made by people who call themselves experts, which are essentially unsubstantiated.

I agree that supplementation can be a 'snake-oil' business, no doubt. However, the fact is that nutritional deficiencies do exist, and they result in medical conditions which are well recognized (and sometimes very serious) and are treated by administering a vitamin or mineral (a supplement) such as B vitamin complex, for instance.

In the realm of hand surgery, particularly when addressing hand pain and nerve pain, there are 5 supplements that I routinely recommend to patients which, in addition to other interventions and modifications, can be extremely useful in alleviating the symptoms of carpal tunnel syndrome or arthritis.

Here they are:

1. MSM and Chondroitin: These are supplements which contain sulfur, and sulfur in turn, is critical for many aspects of health, including skin health (which I write about in my other blog). Specifically, sulfur is crucial in helping create many of the joint cushioning compounds that are found within the joint and can help reduce joint pain.

2. Krill Oil: As opposed to Omega-3 only. Why? Because in addition to high levels of omega-3 fatty acids which are sorely lacking in the modern, industrial society diet, krill oil when combined with hyaluronic acid along with a natural anti-oxidant that is contained with the krill oil called astaxanthin can be very beneficial in relieving joint pain.

3. Magnesium: Both in the form of mineral salt baths and oral supplements. Magnesium is an exceptionally important mineral that is often under-appreciated in it importance in literally thousands of enzymatic reactions. Although it can be taken orally, the transdermal route via mineral salt baths can not only be effective, but also quite soothing for sore joints.

4. Turmeric: This is an ancient Indian spice that has been used for centuries in Ayurevedic medicine for all sorts of uses. In fact, I even recommend it for skin health in the form of a topical cream which I recommend for patients. Turmeric is closely related to ginger, and it's active ingredient is a compound called circumin, which is thought to have many beneficial effects in many different aspects of health, ranging from anti-bacterial and even anti-neoplastic (anti-cancer) effects to anti-inflammatory effects. Although you can take turmeric supplements, one of the best (and tastiest) ways to get more turmeric is to eat it in the form of things like curries.

5. Bone Broth: Consuming bone broth on a regular basis has many beneficial effects, one of which is joint health. Dr. Cate Shanahan writes in her book, Deep Nutrition:

"The health of your joints depends upon the health of the collagen in your ligaments, tendons, and on the ends of your bones. Collagens are a large family of biomolecules, which include the glycosaminoglycans, very special molecules that help keep our joints healthy.”

Indeed, bone broth provides great deal of these special molecules called glycosaminoglycans or GAG's for short, and it will certainly warm you up on those long and dark winter days.