Degeneration

A majority of Americans will experience degenerative changes to the knee and/or lumbar joints and discs, many even in their early thirties. With aging, hip degeneration affects at least a third of the population, and is a major factor in the decline of health with aging, as decreased mobility and increased inflammatory stress will be a major contributor to a variety of common health problems with age. A number of factors contribute to degenerative joint and vertebral disk conditions, and understanding these health problems and causative factors helps the patient and Complementary Medicine physician to devise the right individualized protocol to prevent, reverse, or treat the condition. Restoration of healthy joint and disc tissues is possible, and unless these underlying factors are addressed, large studies show that even surgery may not prevent the continuing degeneration. Integrating Complementary Medicine into your health care may be the most important choice in your life to prevent the pain and debility that often accompanies these degenerative conditions.

By 2011, the strategies of modern medicine to treat degenerative joint and spine conditions are proving to be inadequate. Large studies have shown that arthroscopic surgical repair will not prevent the recurrence of degeneration of the joint if underlying chronic inflammatory conditions are not corrected. The medical community responded to this finding by promoting a prosthetic replacement of joints, but by 2011 many of these prosthetics were failing in a short period of time and causing a problematic deposition of metal particles in the tissues. The failures of metal-on-metal hip replacements will generate many billions of dollars in added healthcare costs, time off work, and future nursing care for invalid patients, adding stress to both the patients and their families, and the government, as rising healthcare costs add to government deficits and increased cost of insurance policies. A more comprehensive and holistic approach to joint degeneration is urgently needed.

Joint degeneration is usually referred to as osteoarthritis, but this term does not apply to all degenerative joint conditions. Arthritis means inflammation of the joint, and there are over 100 medical classifications, or types, of arthritis. Osteo is a term referring to bone, and is used also to refer to the bone covering at the joint, or cartilage, as well. Many cases of joint degeneration are more correctly called osteoarthroses. Degeneration of the cartilage may also be due to metabolic concerns, and this would be classified as chondromalacia, sometimes called “softening of the cartilage”, but referring to inadequate metabolic nutrition delivered to the cartilage, or dystrophy, in many cases. Areas of cartilage degeneration that is attributed to repeated trauma or hard exercise also occur in Osteochondritis Dissecans, and usually involves small loose bodies of cartilage or bone that move in the joint and cause an inflammatory and mechanical wearing on small areas of bone covering, which are referred to as lesions. Often, there is an array of causes, though, and these diagnostic terms may be outdated. The exact causative explanations of joint degeneration are still being debated, and an overview of the scientific understanding on this subject helps the patient and physician to formulate the right individualized treatment protocols to stop tissue degeneration and promote healthy regrowth.

Because of the lack of understanding of the etiopathology of joint degeneration, even the incidence of this problem is not clearly reported, and various medical sources give varying reports of incidence. This is mainly due to the problems with classification of the disease. The Centers for Disease Control in the U.S. report that osteoarthritis is characterized by degeneration of the cartilage and underlying bone within a joint, and is seen in about 14% of the population, and close to 34% of the aging population, but specifies that this is believed to be a very conservative estimate. Females experience osteoarthritic joint degeneration at about a 2-3 to 1 ration over males. The incidence of lumbar disc degeneration is often reported to exceed 50% in the aging population, and even exceeds 20% in the young population. This high incidence of degenerative joint pathologies has led to a competitive attitude concerning treatment protocol, with much discouragement of more conservative treatments in Complementary Medicine, and a push for new surgical technologies and prostheses. Many patients who are developing conditions of joint degeneration, though, are placing their hope in a more integrated approach, and not waiting until the condition is severe and a joint replacement prosthetic seems the only option. Too many patients have been talked into a joint replacement prosthetic too soon, not realizing the future ramifications of this decision.

In 2010, with the number of hip replacements performed approaching 200,000 per year and climbing, the number of complaints of adverse events and failure of the metal-on-metal hip replacements alone, which account for over 60,000 of the prosthetics implanted per year, reached over 5000 per year. By the end of 2011, the number of failures of metal-on-metal hip prosthetics mushroomed to a catastrophic number. The New York Times reported in a December 28, 2011 article entitled Common Failure of Hip Implants Bring Big Costs (Harry Meier) that an estimated 500,000 patients had received an all-metal hip replacement prosthetic by 2011, accounting for over a third of the hip replacement prosthetics until alarming reports of failure prompted large recalls and discontinuation of these types of prosthetics. A single type, manufactured by the DePuy division of Johnson and Johnson, was implanted in 40,000 patients in the United States, and recalled in 2010 due to a high rate of failures and adverse risks from metal debris in the surrounding tissues and circulation. The metal debris resulted from both movement of parts against each other and corrosion. In 2011, the Bloomberg report stated that the failure rate of this one type of prosthetic in the United Kingdom reached 49 percent by year six after the first revision. The settlements of these cases involving failed prosthetic joints has generated remarkable financial liability for patients, as hospitals and insurers often settle for a relatively small recompense and pass the remainder of the bills to the patient, according to the New York Times investigation. For patients receiving a direct settlement, liens from the insurers and hospitals often are much larger than the personal settlement, creating enormous economic stress for the patient, who is usually unable to work. The Times article cited a recent study that showed that in the last 5 years, no new artificial hip or knee replacement device introduced to the market was more durable than older devices, and some 30 percent of these “advanced” devices were less durable than older models. An FDA report, however conservative, reveals that the metal flaking and release of metal ions into circulation presents a real risk. Click this link to see the FDA warning:http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/MetalonMetalHipImplants/ucm241604.htm.

An article in the February 22, 2012 New York Times, entitled Hip Maker Discussed Failures, outlined the evidence that the maker of a recalled hip prosthetic, Johnson and Johnson and its subsidiary DePuy Orthopedics, knew of the early rate of failure of a metal-on-metal prosthetic hip replacement that was inserted in over 93,000 individuals, and delayed action on recalling the prosthetic. Widespread clinical reports that the artificial hip was failing in less than three years for many patients was attributed to failure by the surgeons in company memos. The prosthetic is known as an articular surface replacement, or ASR. A year before the recall, an internal email that has since been uncovered, revealed that the FDA had refused to approve the device, yet the FDA report had been kept confidential, rather than publicly reported. The hip prosthetic had experienced a high rate of failure, or need for early revision (a second prosthetic surgically inserted), during the clinical trials of the device. The FDA does not release such decisions of non-approval as a matter of policy, citing protection of confidential business information. The decision of the FDA to deny approval of the device was not passed on to doctors, hospitals, clinics and patients as the prosthetic was marketed. Instead, the device was heavily marketed abroad in 2003, while a version of the prosthetic was marketed in the United States, which was later the subject of the 2009 FDA decision. Despite this evidence, the company executives continue to assert that the decision to stop selling the device was “purely a business decision”, reflecting declining sales.

In response to these alarming failures of the hip replacement prosthetics surgeons in the United States did not recommend increased caution and a return to use of the prosthetic hip replacements on a more narrow subset of elderly patients with severe degeneration, but instead touted a new type of metal-on-metal hip prosthetic called “resurfacing”. This type of hip replacement was heavily promoted to younger patients with the promise that less of the femur, or thigh bone, was removed, leading to safer outcomes, more mobility, and a greater degree of success with replacement of the prosthetic. In reality, studies showed in 2012 that the outcomes for these hip prosthetics were not better than other metal-on-metal hip replacements, but did come with one advantage for the doctors, clinics and manufacturers, namely that the patient could not sue for failure. A New York Times article of October 2, 2012, entitled Warning About Alternative Hip Implant Procedure stated that while traditional metal-on-metal hip prosthetics have largely disappeared due to the large number of lawsuits, the FAD ‘fast-tracked’ the new resurfacing type with clinical trials from the company showing favorable data. Researchers at the University of Bristol, UK, headed by Dr. Ashley W. Blom, followed 32,000 patients with these “resurfacing” metal-on-metal hip replacements, though, and found that women and younger men had an “unacceptably higher” early failure rate than even the traditional metal on plastic early hip prosthetics, and that the same problems with metal molecule “flaking” existed. Experts are now questioning the way these devices were “fast-tracked” by the FDA. Dr. Sedrakyan, a researcher at Weill Cornell Medical College of Cornell University, was quoted: “If resurfacing hip replacement devices are found to be unsafe, then the implications are grave.” The manufacturers, such as Smith and Nephew, replied that these resurfacing hip replacements were intended for a target population of older men of larger stature, with bigger femurs, and took no responsibility for the marketing of these devices to women and younger men. Unfortunately, these many patients will early failure and health problems related to metal ion toxicity will not be able to sue for damages in the United States.

We have known for some time that there was a big problem with hip replacements, with even a successful prosthetic providing only a short number of years of function. A relatively small number of hip replacements are maintained in healthy individuals for up to 15 years, which is considered the best outcome. Most experts in 2012 state that these hip replacements are “supposed” to last 10 years before requiring a replacement. For a large percentage of patients, though, this time span is considerably shorter. In 2002, an NIH population study by Brigham and Women’s Hospital, Harvard Medical School found that over 37,000 revisions (replacement surgeries) were performed each year in the United States, at the cost of over $31,000 per surgery. Since 2002, this number, and the costs, have grown dramatically. The full recovery time often reaches 6 months, adding the cost of time off work and rehabilitative therapy. Revision replacements have a higher incidences of failure and adverse effects, and a shorter life span of the prosthetic. A third revision is almost never successful, eventually leaving the patient an invalid. While the advances in total hip and knee replacements are remarkable, many intelligent patients are opting for a more conservative course of joint rehabilitation before resorting to this problematic and risky solution. While standard medicine continues to imply that the only options are mild exercise and corticosteroid injections, the research today shows that a treatment protocol integrating acupuncture, electroacupuncture stimulation, herbal and nutrient medicine, direct soft tissue physiotherapy (Tui na), and proper neuromuscular reeducation is able to stimulate functional regrowth of the joint cartilage and surrounding tissues, and reverse osteoarthritis, which accounts for about 94 percent of the cases receiving hip and knee replacements. In addition, recent research has found that specific herbal chemicals may reverse or control rheumatoid arthritis, and may also be combined in a total treatment package with acupuncture, nutrient medicine and physiotherapy.

Degeneration of the Knee joint and cartilage

Degeneration of the knee joint may involve a variety of tissues. In most cases, the cartilage, or tissue covering the bone at the joint, is softened and degenerated, sometimes until parts of the cartilage are almost completely absent. In other cases, the joint meniscus, a fibrocartilaginous structure of the knee joint, with a crescent or horsehoe shape, is degenerated and experiences a number of small tissue tears. The ligaments of the knee, especially the interior ligaments, or cruciates, are also involved in many cases. Ligaments are fibrous tissues connecting and stabilizing two or more bones, cartilages, or other fascial tissues of the joints. While many patients associate tears of the ligaments and meniscus with injury, the majority of these cases do not involve trauma.

For many years, it was assumed that “wear and tear” was primarily responsible for these tissues experiencing degeneration. In the knee, there are two areas with cartilage, or bony covering, namely, the cartilage of the primary bones (femur, tibia and fibula), and the cartilage of the moving kneecap (patella). The degeneration of the patellar cartilage is still referred to as “runner‘s knee”, revealing the past prevalent notion that most cases were due to mechanical wearing down of the cartilage. The actual term is chondromalacia patella, implying that insufficient circulation of nutrients is mainly responsible for the degeneration of the patellar cartilage, with wear and tear merely contributing. Degeneration of the cartilage of the primary bones is mainly due to osteoarthritic changes, and this has a more multifactorial cause. A combination of poor tissue nutrient delivery (malacia), improper mechanical stresses, inflammatory dysfunction, and hormonal changes are believed to be the main underlying factors contributing to osteoarthritic degeneration of the cartilage of the primary bones of the knee. Obviously, a thorough and holistic approach to treatment is needed to address these factors, as well as a time intensive and individualized approach. Standard medicine does not deliver this type of treatment approach, but integration of the more cost effective and time intensive treatments in Complementary Medicine could fulfill this need. The specialty of the Traditional Chinese Medicine (TCM) includes physiotherapies (Tui na), herbal and nutrient chemistry, acupuncture and electrical stimulation, and patient instruction in therapeutic regimens and correction of postural mechanics.

The study of cartilage degeneration has revealed much about the disease mechanisms, and thus much about the needed treatment protocol, which must address a variety of factors. This study of cartilage degeneration, or osteoarthritic changes, is not new. For instance, a study from 1969, at the Institute of Orthopaedics at the University of London, and the Royal National Orothopaedic Hospital in Stanmore, Middlesex, UK, by S.Y. Ali and Lois Evans, revealed that degenerative cartilaginous diseases showed a loss of protein-polysaccharide (glycoprotein) component and fall in the production of chondroitin sulphate. The deficiency of the cartilage cells, or chondrocytes, in the production of condroitin was related to the glycoprotein changes. These glycoprotein changes were correlated with increased enzyme activities stimulated by chronic inflammation in the surrounding tissues. Acidity changes also stimulate enzymatic tissue degradation in the cartilage, with a maximum breakdown of cartilage and glycoprotein at pH5, with a release of over 50 percent of the chrondromucoprotein content quickly. Acidity levels are highly correlated with enzyme activity rates. Cathepsins, or protease enzymes, in the cartilage cells were thought responsible for this loss of glucosamine and chondroitin. These proteolytic enzymes called protease cathepsin break down other proteins. A balance of cathepsins is needed to maintain tissue homeostasis, and imbalance of inflammatory processors, and mediators, as well as chronic acidic states, lies at the heart of cartilage degeneration. Eventually, glucosamine and chondroitin supplements were recommended, but taking these orally have limited effect. Chemicals to inhibit cathepsins would be problematic, as these protease enzymes also regulate many important and beneficial processes in the body, preventing amyloid plaques in Alzheimer’s disease, the spread of some cancers, denervation in diseases such as multiple sclerosis, etc.

To aid restoration of the cathepsin protease metabolism and stop the cartilage degeneration, a number of therapeutic aids should be used. Regulation of inflammatory processes should be paramount, then clearing of diseased and dysfunctional tissues with antioxidants and proteolytic enzymes, and finally the supply of depleted proteins, such as DL-phenylalanine, L-arginine, L-leucine, and L-glutamine. The hydrolysis of the chymotrypsin substrate benzoyl-DL-phenylalanine 2-naphthyl ester accounted for much of the breakdown of cartilage at pH5, with an imbalance of the cathepsins A and B. Supplementation with DL-phenylalanine is thus an important constituent of therapy, and may also prevent the excessive breakdown, or catabolism, of endorphins, the important opioid neurotransmitters that facilitate pain relief. Cathepsin D was also shown to have a potent proteolytic activity involved in the cartilage breakdown. This enzyme uses aspartate and is more active at acidic pH. Aspartic endopeptidases are also seen in fungal and retroviral microbes, and potentially could link systemic problems with Candidiasis, as well as retroviral infections of a low-grade, to cartilage degeneration. Many studies show links between ill health of the intestines and the so-called “leaky gut” syndrome to chronic joint pain and degeneration. Such study links improved gastrointestinal function to improved status in arthritic conditions. While this scenario is complex, and is different from one patient to the next, the evidence does point us in the direction we must take to reverse joint degeneration. It appears that scientific study indicated a need for a holistic protocol long ago, but this was largely ignored. Restoration of cartilage and reversal of this degenerative process is possible, but success is unlikely unless a thorough, thoughtful, and holistic treatment protocol is applied.

Often, a combination of destructive and productive changes occur in joint arthropathies, and when the destructive activity exceeds the productive restoration, an eventual degeneration of the joint occurs. The key to treatment is early recognition of this condition, and an array of therapeutic steps taken to decrease the destructive changes and increase the productive. Erosive arthritis is the prototype of this type of arthritis, and an array of problems may contribute to destructive degeneration of tissues, such as episodic bursitis, gout, pseudogout calcification, patellar tracking syndromes, and altered biomechanics. Often, myofascial syndromes contribute to altered biomechanics, and a simple correction of chronic myofascial stress imbalances will do much to correct this destructive mechanical force. Both correction of destructive forces and encouragement of circulation and productive mechanisms are needed to restore the healthy daily regrowth of joint tissues. Degenerative conditions of the joints occur when normal maintenance of the joint tissues is inadequate to counter mechanical stresses and/or inflammatory diseases. Side effects of medication may also play a significant role, as well as metabolic deficiencies. Many medications list joint pain as a significant side effect, such as cholesterol lowering statins, gastric acid inhibiting drugs, antibiotics, medications treating high blood pressure, biphosphonate drugs used to treat osteoporosis, etc. By the time joint pain becomes debilitating the degenerative process is already advanced. The patient must look at three approaches to this problem: 1) pain relief, 2) identification of the causes and contributors to the tissue degeneration and subsequent correction of these problems, and 3) restoration of healthy tissue and proper response of the inflammatory mechanisms to clear unhealthy tissues and replace them with new healthy growth. Most patients are only focused on pain relief, and this is a grave mistake, as palliative treatment alone will lead to a worsening of joint degeneration in many cases, and restoration of the joint homeostasis becomes more difficult in later stages.

In the recent past, standard medicine led the patients to believe that arthroscopic surgery would correct problems with degenerative knee joints. More recent evidence suggests that many arthroscopic knee surgeries to repair meniscus tears may be unwarranted, and that the problem will recur due to degenerative arthritic conditions. In a New York Times article in the Health section on December 8, 2008, Dr. David Felson, a professor of medicine and epidemiology at Boston University, explained a study of 991 people ages 50 to 90, some with knee pain and some without, that were examined with multiple MRI scans to determine the frequency and meaning of meniscal tears in the general population. The conclusions, published in the New England Journal of Medicine, were that meniscal tears were just as common in arthritic joints without pain as those that produced pain, and so repairing the joints surgically was not the answer to eliminating the pain. Dr. Felson found that 40 percent of the general population had meniscus tears at age 60, and there was little correlation between these tears and the pain. He believes that arthritis and chronic inflammatory degeneration are the cause of most knee pain in the aging population, and that conservative care should be utilized to correct this problem. TCM can deliver this conservative care.

Real restoration of the joint tissues depends on concurrent physiotherapy and use of aids to help the body with tissue regeneration. Once the patient learns to correct problems with body mechanics that continue to injure the joint, and corrects other problematic causes of tissue degeneration, such as chronic inflammatory states or diseases, tissue regeneration is possible, even with cartilage. Sometimes arthroscopic surgery is absolutely necessary to clean up dead tissue so that healthy tissue may grow, but the surgical assessment should consider the actual need and benefit realistically, and work in an integrated fashion with other health professionals to achieve regrowth of healthy tissues and take care of problems that contribute to chronic joint inflammation. Post surgical care should include passive mobilization, myofascial release, acupuncture, herbal medicine, and nutrient therapy to aid healthy repair and regrowth of the joint cartilage, ligaments and tendon attachments. Health concerns that contribute to arthritis, or poor inflammatory function, should be addressed holistically.

"Modern medicine is turning to less invasive and more holistic protocols such as prolotherapy, laser surgery and other minimally invasive surgical techniques combined with a comprehensive package of support therapy to promote healthy restoration of the arthritic joint. Health authorities such as the Mayo Clinic state that therapies such as prolotherapy alone will not result in a healthy regrowth of cartilage and joint tissue. This is where the use of Complementary Medicine comes into play."

Prolotherapy is an example of the new attitude taken by the medical community to degenerative joint conditions. In this therapy, also called sclerotherapy, sugar or nutrient solutions are injected repeatedly into the deteriorated or degenerative ligaments, joint capsule soft tissues and tendon attachments to stimulate regrowth of the fascia, or connective tissue. Prolotherapy produces an inflammatory response in these soft tissues to stimulate regrowth, but as the Mayo Clinic reports on their website, prolotherapy alone is not proven to be beneficial. It must be combined with an array of Complementary therapies to achieve success. Since prolotherapy injections are performed every 3-6 weeks during the course, integrating this array of complementary therapies is not a problem. Utilizing acupuncture, topical herbal medicines, and nutrient medicines, all of which have shown clinical proof of benefit to arthritic joint conditions, along with direct soft tissue physiotherapies, such as TuiNa and myofascial release, the ultimate success with prolotherapy is greatly enhanced. Therapies such as prolotherapy and arthroscopic surgical repair may be utilized by the patient with advanced joint degeneration, but it would be a big mistake to assume that these interventions alone will restore joint health. If the underlying mechanisms that led to joint degeneration are not addressed, the same joint degeneration will recur.

Prolotherapy produces an inflammatory response in the joint tissues to promote healthy growth, and we can understand from this approach the necessity of improving the inflammatory functions in the body. While anti-inflammatory medicines such as ibuprofen and naprosen may relieve pain temporarily, the inhibition of inflammatory processes may result in long term degeneration rather than healthy tissue restoration. Corticosteroid injections, which may promote the inflammatory process and modulate it temporarily, will also cause joint degeneration if repeated too often, and a new clinical trial comparing long-term outcomes of PRP (platelet-rich plasma injection) and corticosteroid injection showed that corticosteroids provided no improvement in long-term outcomes of pain and disability (see NY Times article cited below). Corticosteroids come with considerable health risk when a patient is taking multiple products with synthetic steroids chronically, and synthetic steroids are now found in many prescription and over-the-counter products. The real benefit of corticosteroid injection is a short-term relief of pain that provides a window of opportunity for the patient to utilize an array of conservative treatments to achieve better tissue healing. Complementary and Integrative Medicine provides this array of treatments, combining phyisotherapies with acupuncture, herbal medicine, topical herbs, nutrient medicine, and patient instruction to ahcieve maximum results. Complementary Medicine also utilizes the inflammatory mechanism to do what it is supposed to do, not just create pain, but to repair the tissue. Herbal and nutrient medicine may optimize the inflammatory response to promote the natural tissue healing mechanisms built into the body. For this to work a comprehensive and holistic approach must be taken that insures that your immune response and inflammatory tissue repair works optimally.

One type of injection that has been utilized more frequently in recent years for degenerative joints, especially for osteoarthritic knee joints, is hyaluronic acid. A multicenter placebo-controlled trial of the effects of this therapy in France was completed in 2008, and the results indicated that a single injection of hyaluronic acid produced no better results than placebo (see additional information below). Hyaluronic acid is a substance found in normal joint fluid and tissue, and is a major component of synovial fluid, which lubricates and protects the white tissues of the joints. While a single injection of hyaluronic acid proved ineffective, probably because tissue receptors for hyaluronic acid limit the cellular intake from a large dose, repeated topical use of a small amount of hyaluronic acid has proven beneficial for some dry joint tissues, especially if administered with a carrier substance. Research is also progressing on the effects of a small amount of pure hyaluronic acid take sublingually and distributed to receptors via blood circulation. This is just one facet of a comprehensive package of therapy that may be needed to achieve healthy repair and regrowth of the degenerated joint tissues. By studying this article, the patient with joint degeneration can gain understanding of the best therapeutic aids in Complementary Medicine and combine these into an effective package of care.

A third type of injection involves platelet-rich blood plasma (PRP), which theoretically releases growth factors and nutrients to speed the growth of healthy joint tissues. This therapy has faced much criticism, though. A 2010 article in the New York Times, entitled Popular Blood Therapy May Not Work, reports that the editor of The American Journal of Sports Medicine, Dr. Bruce Reider, describes this procedure as “platelet-rich panacea”, and the head researcher at Hague Medical Center in the Netherlands, who performed the first extensive rigorous study of effects, reported that the injections performed no better than the salt water placebo used in the randomized clinical trial. Dr. Johannes Tol stated: “We are sorry for the patients, there is still no good treatment (for cartilage degeneration).” The PRP injections are still being used to treat degenerative knees in sports medicine, but are not paid for by the insurer. A rigorous protocol of physiotherapy and other conservative treatments is always used in these cases of high profile athletes receiving PRP, though, and if a patient chooses to pay for this therapy, integrating the physiotherapy, acupuncture stimulation, herbal and nutrient medicines that are backed by sound research would seem sensible.

"No single supplement or herb will work to achieve eventual repair and regrowth of healthy joint tissues when degenerative joint conditions and osteoarthritis or chondromalacia occurs. A package of care includes a combination of research-based medicines along with sensible physiotherapies, correction of body mechanics, and stimulation of both the joint and the systems in the body responsible for tissue maintenance and regrowth."

Joint tissues have no direct significant blood supply, and thus depend upon movement to push fluids in and out of these tissues. The white tissues are the cartilage, meniscus, ligaments and tendons, and these are the tissues that degenerate in the joint. One reason that they degenerate so severely in osteoarthritis is because the bone covering, or periosteum, which does have abundant blood and lymphatic vessels, is absent where cartilage covers the bone at the joint. Instead we normally have layers of cartilage where bone meets bone, and these layers are supplied with nutrients from two directions, the vascularized muscles, and the vascularized bone. When degeneration occurs in the bone and cartilage, spurs or osteophytes, and changes in the bone underlying the cartilage, occur, where this outer bone is converted into a dense smooth ivory-like substance (eburnation), preventing the lower layers of cartilage from getting the necessary blood supply from the richly vascularized bone and also preventing the normal conversion of cartilage into new healthy bone. This basement layer of your cartilage is composed of a type of cartilage cell that creates hyaline and type II collagen. This layer of cartilage near the bone is normally oxygen-rich, from the bone blood supply, and a lack of oxygen accounts for poor hyaline formation. Injection of hyaluronic acid alone will not correct this problem, and only restoration of these cartilage cells that produce hyaline will achieve proper lubrication and decrease of pain.

Cartilage is constantly growing and being replaced in the body, although this regrowth is slower than most tissues due to a lack of intrinsic blood nutrient supply. When degeneration of the cartilage exceeds the regrowth, the thickness decreases and eventually leaves the bone unprotected at the articular surface. Regrowth is obviously possible, and to regenerate cartilage this regrowth needs help. Hyaline cartilage is composed of 4 distinct layers, with the superficial layer softer and the less dense, but with a much greater collagen content. The superficial layer is believed to be the first to degenerate, and many experts now believe that this is because the hard calcified cartilage layer near the bone does not turn into bone fast enough. The cartilage cells, or chondrocytes, change in form and function from the superficial to the deepest layer, from a less dense elongated form that secretes little proteglycan, to rounded chondrocytes arranged in columns alongside thicker collagen fibers. Restoration of normal homeostatic changes in these cartilage layers is the key to rebuilding cartilage, and this requires a holistic protocol. A step-by-step therapeutic approach is necessary to regain the healthy metabolism of lubricating hyaline and formation of new collagen. A combination of passive joint mobilization, stimulation with acupuncture and electrical stimulation, increased blood flow, healthier immune reaction, antioxidant clearing, and tissue nourishment with type II collagen, and perhaps hyaluronic acid included in the comprehensive treatment protocol, is the logical course to increase the success of this therapy.

Collagen type II is the main rebuilding material for both joint tissues and bone, and when a repair and regrowth is stimulated with a package of proper therapy, an enormous amount of this material is needed by the body. Unfortunately, for many patients with degenerative conditions, not enough collagen type II is produced by their cells. The subject of delivery of exogenous collagen type II to the patient has been studied for some time. Initially, it was hoped that glucosamine sulfate and chondroitin could be take orally and provide a better production of collagen type II and joint tissue regrowth. Unfortunately, taking these supplements orally has little effect at the joint because the digestive process breaks down these substances before they reach the joint in the blood circulation. Research at Harvard University has progressed to the completion of two human clinical trials utilizing purified extracts of bioidentical collagen type II from chicken tissues. Methods of extraction, purification, and now encapsulation with an eggshell glycoprotein, has produced a type of collagen type II that can be taken orally and is proven to reach the affected joints. Utilizing a health professional, and dependable professional products such as these, is very important to the success in therapy. When utilizing this research-based nutrient, it would be more effective when the joint is receiving proper physiotherapy and stimulation, when the patient is progressing with targeted stretch and exercise, and when other research-based herbs and supplements are used to promote circulation, tissue repair, and antioxidant clearing. One potent antioxidant is derived from pomegranate, not just the juice, but the inedible parts of the plant also, which contain potent OPCs that have been proven to also modulate the immune response that drives osteoarthritic degeneration, with excess of interleuin-1.

Unhealthy collagen may also be a problem in chronic joint pathologies and degeneration. It has been demonstrated in studies that advanced glycation endproducts (AGEs) may cause oxidative stress and stiffened collagen cross-links that are problematic for both joint tissues and bone. In autoimmune reactions, such as Rheumatoid arthritis, unhealthy collagen may be an important trigger of autoimmune reactivity. The Harvard studies of collagen extracts have proven in clinical human trials that this patented form of collagen supplement significantly replaces unhealthy collagen in both Rheumatoid arthritis and osteoarthritis patients. Decrease of AGEs and AGE receptors may also significantly improve chronic arthritic degeneration. Since the glycation Maillard reactions in collagen and vascular endothelium may occur on protein residues, effective proteolytic enzymes may also be useful in the overall protocol. These problems with AGEs and poor tissue quality are especially suspect in patients with metbolic syndrome (insulin resistance or Diabetes type 2), but are also noted as a physiological problem associated with normal aging. Measurement of increased urinary excretion of key AGEs, such as pentosidine, have been highly associated with osteoporotic vertebral microfractures in studies as well. These bone degenerative conditions may be an important part of the pathology in chronic lumbar joint degeneration and subsequent arthritic conditions.

Not only the white tissues of the joint, capsule, ligament and tendon, but also the bone covering, or cartilage will need to repair and regrow. More advanced study of the physiology of this cartilage near the bone has indicated that activated Vitamin D3 hormone, or 24,25-(OH2) D3, is essential to regulation of the healthy calcification of this layer of cartilage. When calcification slows, the cartilage near the bone becomes hypertrophied, or swollen, preventing both circulation to the tissue, as well as inhibiting the growth mechanism of the more surface layers of cartilage. Restoration of this D3 hormone mechanism involves more than just taking Vitamin D. Hormone balance is essential to the Vitamin D3 metabolism. Restoration of healthy hormone balance may thus be needed in certain patients with degenerative cartilage. In the healthy individual, most of our Vitamin D3 cholecalciferol prohormone is generated in our skin with frequent exposure to sunlight for short periods at midday. This cholecalciferol is then transformed, via a number of enzymatic steps, tightly controlled by endocrine feedback regulation, into the activated hormone D3 forms that we need. This occurs mainly in the kidneys. To restore potential D3 deficencies that may be greatly contributing to your degenerative cartilage and joint conditions, a thorough holistic approach is recommended, and professional guidance may be necessary. The book entitled Cartilage, by Brian Keith Hall and Stuart A. Newman thoroughly outlines these findings, and states: ”What distinguishes chondrocytes (cartilage cells) of the growth plate from other chondrocytes would appear to be their ability to respond to environmental regulation by Vitamin D metabolites in a manner not shared by other chondrocytes.“ What this means is that for patients with chronic degenerative cartilage, no matter what the cause, surgical correction and supply with nutrients such as glucosamine and chondroitin will not achieve ultimate goals of restoration without a healthier hormonal support. This type of increased hormonal health can only be achieved with a holistic approach.

A second type of joint degeneration occurs with repetitive wear and tear to the upper layer of cartilage, and this is called chondromalacia, or commonly ’runner's knee‘. In this degenerative condition, the upper layers of cartilage, usually under the patella, degenerate due to poor regrowth when patellar motion wears away the surface of the underlying cartilage. Uneven muscle tension and/or joint subluxation may be the cause of this abnormal abrasion of the patella against the cartilage. Most cases occur in young athletic individuals, especially women, whose wider pelvic structure may create more lateral force on the patella. Masking of the pain with non-steroidal anti-inflammatories and steroid injections may actually contribute to the degeneration because these allow the athlete to continue with harmful activities instead of resting and affecting repair. Using conservative therapies early in the syndrome may be the best advice one could get. After the chondromalacia has become chronic, there are few standard treatment options. Surgical correction has produced very few good outcomes, and often the patient is told that they may have to endure chronic pain until a full knee replacement is justified later in life. The patient wants to hear a more optimistic treatment plan than this. Since our body's tissues constantly regenerate, there is never a reason to believe that with proper treatment protocol, that restoration of healthy cartilage surface cannot by achieved. It only takes work, time, and the care of a knowledgeable Complementary Med physician who combines the various treatment strategies in a logical manner.

No matter what type of cartilage degeneration has occurred, whether due to aging and hormonal imbalance coupled with malnourished tissues, or primarily due to wear and tear, we do know that promotion of regeneration involves neovascularization and growth factors. VEGF, or protein vascular endothelial growth factor, is one of the most important factors in stimulating this regeneration. A 1999 study at the Department of Cardiovascular Research of Genentech, in San Francisco, California, coupled with research at the University of California San Francisco (UCSF) (Han-Peter Gerber et al; Nature Medicine(5): 623-628), found that angiogenic VEGF, when chemically blocked, resulted in degeneration of the cartilage and impairment of trabecular bone formation, with unhealthy hypertrophy of unhealthy tissue around the bone. The researchers found that “VEGF-mediated capillary invasion is an essential signal that regulates growth plate morphogenesis and and triggers cartilage remodeling.” Promotion of VEGF and regulation of the factors that inhibit VEGF function, such as inflammatory and oxidant stress, are thus very important to regrowth of healthy cartilage. Research is exploring the effects of Chinese herbs, electroacupuncture stimulation, recombinant plasmid VEGF, and manipulation of blood proteins that can be injected into the area of cartilage degeneration to promote VEGF and cartilage growth. Research in China is exploring the combination of recombinant gene therapy, herbal medicine and electroacupuncture to achieve these goals, and this has shown success. Integrative Medicine may play an important role in achieving better results in the difficult arena of cartilage regeneration in the future.

Current trends in the U.S. are limited to advanced surgical techniques, such as microfracture, laser chondroplasty, grafting and cartilage plugs, and thermal chondroplasty. Unfortunately, these abrasive techniques stimulate the growth of fibrocartilage, not articular cartilage, leaving the patient with a prolonged process of regenerating actual smooth cartilage over the fibrocartilage. This long rehabilitative process lasts from 6 months to 2 years, and the fibrocartilage allows light use of the joint without symptoms, but with increased load bearing and heavier use, pain and swelling are expected. Current study shows that about 20-30 percent of patients do not recover full use of the joint after these procedures, even at 2 years. A comprehensive package of care, integrating Complementary Medicine intelligently, is needed, even when these procedures are utilized. Maintaining movement of fluids in and out of the regenerating cartilage, good circulation, myofascial release to decrease mechanical stress, and a potential for rebuilding not only the chrondrocytes, but the extra-cellular matrix, is extremely important. A narrow focus is a ticket for failure.

Assessing the long term outcomes of total knee prosthetic replacement

Because of the amount of research data in the last decade that has cast a discouraging light on surgical repair of degenerative knee joints when used alone, and the continued reluctance to utilize an integrated conservative approach to healthy restoration of knee joint tissues, many orthopedic specialists have turned to total knee prosthetic replacement as the treatment of choice. Many patients report that the advice given is to wait until the knee is degenerated enough to warrant total knee replacement, since there is no standard therapy that will restore degenerated cartilage and meniscus, especially when there is evidence of arthritic disease. This article presents research that shows that a number of therapeutic protocols are now proven to aid regeneration of cartilage. Patients are also led to believe that the total knee prosthetic replacement will result in a pain free functional state without significant complications. Often times, the long term outcomes presented by the surgeon are overly optimistic. Long term outcome data is still relatively scarce, but the federal government has released some analysis of early long term studies as part of the AHRG (Agency for Healthcare Research and Quality), a mandated part of the U.S. Department of Health and Human Services.

The AHRQ Total Knee Replacement Summary (No. 86) reports that total knee arthroplasty (prosthetic replacement) is now one of the most common orthopaedic procedures performed. The AHRQ states that although previous industry reports were very positive, that “based on conclusions from consensus panels or surveys of health care providers, there is considerable disagreement about the indications for the procedure.” This means that some surgeons may advise a patient to have a total knee prosthetic replacement, while other surgeons may advise that the particular case does not warrant the knee replacement when considering other options, and weighing risks versus benefits. The AHRQ report does report a good rate of success for the procedure, although, when looking closer at the data, there are troubling questions that arise. Since total knee replacement is a relatively new procedure, and the patient wants the knee to perform without problems for the rest of their life, we look to long term study data to help us decide whether the knee replacement will eventually present serious problems. Unfortunately, the AHRQ meta-analysis only considered literature data from standard medical journals up to 2003. Advances in design, and favorable industry reports, have produced a dramatic increase in the number of total knee replacement arthroplasties since 1997. The industry itself still relies on the most favorable study of long term outcome, the 1994 Ranawat study, which reported a 95.6% success at a 14-year follow-up. Dr. Chitranjan Ranawat heads Ranawat Orthopaedics at a hospital in New York that specializes in total arthroplastic surgery, called the Hospital for Special Surgery, and the report is a study of the total knee arthroplasties performed at this prestigious hospital. In many, or most, cases, the knee replacement does not last anywhere near this rosy picture of 14 years. In fact, in 2010, a new type of artificial hip designed to last 15 years or more, was found to fail at an unusually high failure rate after just a few years due to a relatively rapid degeneration of the tissue to which the orthotic attaches. Unlike new drugs, medical implants and devices can be introduced to the market without long-term clinical trials if they resemble a device or implant already approved. To see a New York Times article on this subject, click here: http://www.nytimes.com/2010/12/17/business/17hip.html?_r=1

The AHRQ meta-analysis up to 2003 reports that the median age for total knee arthroplasty was 70 years of age, and 2/3 of the patients in clinical studies were women, with about 1/3 considered obese. About 90% of the participants in the studies had been diagnosed with osteoarthritis. In the studies, 0-56% of the patients receiving the procedure for the first time did not participate to completion of the study. The studies followed patients for between 45 and 67 months (about 4 to 5.5 years). The studies noted that when considering the baseline knees (those not receiving total knee arthroplasty) that the length of follow-up was between 68 to 90 months. The AHRQ panel recommendation, though, suggested a 10 year follow-up, and this is the source of much criticism of industry studies. Of surviving patients, there is a high rate of a need for a second total knee replacement by the sixth or seventh year, and due to degeneration of the tissues surrounding the prosthetic, and the risks of the surgery for patients over 80 years of age, a third total knee replacement is not considered viable as a general guideline. This means that in consideration of total knee arthroplasty, the patient must consider general time of good function and pain relief provided. The patient must also consider that there is a lengthy period of recovery and rehabilitation needed after the first total knee replacement, usually involving considerable pain. Often, the outcomes for this procedure are good after the first year, but by the sixth or seventh year, the prosthetic and attaching tissue are again severely degenerated. The AHRQ study shows that the industry has evaluated this optimal window, and failed to provide data for the time when many, if not most, of these prosthetic procedures fail.

The AHRQ meta-analysis also reports that there is a surgical complication rate within 6 months of surgery of 7.6% of total patients. Anti-coagulant drug therapy was the treatment of choice to prevent deep vein thromboses, despite positive findings for techniques of continuous passive motion and other mechanical means of treatment, which would have a far lower risk of side effects and risks. Failure of the prosthetics over time is expected in many cases, and the number of total knee arthroplasty replacements was high through 2003. The ARHRQ study found that within the five year study time, only about 2% of patients needed a second total knee replacement, but there was insufficient data in the industry studies to assess the number after 5 years, when the first knee replacement is expected to fail. Following the second total knee replacement the AHRQ meta-analysis found that the global knee score (standard measure of pain and function) was about 66 to 80 following this procedure, on average. The AHRQ states that there is no formal basis for translating the size of scores, and that the industry only looks at improvement over pre-operative state, but that a generally accepted rule of thumb is that a score of less than 60 is considered poor, and a score between 60 and 69 represents a fair score (85-100 is considered excellent). The pre-operative scores for these patients ranged from an average of 35.4 to 51.5, indicating that these patients experienced considerable pain and dysfunction. Complications following the second knee replacement in the meta-analysis occurred in 26.3 % of the patients, although only 12.9% of these complications involved the knee, meaning that 13.4% of patients had other health complications after the surgery.

What the AHRQ meta-analysis of knee replacement up to 2003 shows is that within a time frame of 5 years, the surgery is very successful for the 50% of patients studied that did not drop out of the study or die during the study period. No analysis of the percentage of patients needing a second total knee replacement after 5 years was available. Post-operative complications with the first total knee replacement occurred in 7.6% of the knee replacements, with the vast majority involving deep vein thrombosis, which involves considerable risk of stroke or heart attack. Post-operative complications in total with the second total knee replacement occurred in 26.3% of patients, with about half of these health problems occurring in the rest of the body besides the knee. Standard assessment of pain and function showed that the patients generally obtained a poor to good range after the second knee replacement. Study data in the AHRQ meta-analysis was apparently insufficient to rate the actual pain and functional status following the first knee replacement within the first 5 years, but the report states that a “mean effect size” was considered large in magnitude and varied from 1.3 to 3.9 depending on the means of measuring the functional state and duration of followup. Of course, to the general public, this is incomprehensible. The term “mean effect size” refers to an average of the variety of measures of treatment effect, which are combined to calculate treatment success according to a statistical method that is chosen. The British Medical Journal states in its explanation of clinical evidence regarding the use of a mean effect size: “we avoid if possible. Standardized mean differences are very difficult for non-statisticians to interpret and combining heterogenous scales provides statistical accuracy at the expense of clinical intelligibility. We prefer results reported qualitatively to reliance on effect sizes.“ In other words, the AHRQ report does not give the patient much real information to actually assess the pain and functional results of this surgery even within the optimal 5 year life of the prosthetic. To review this AHRQ meta-analysis, click here: http://www.ahrq.gov/clinic/epcsums/kneesum.htm

A 2010 meta-analysis in Europe, conducted by the WHO Collaborating Center for Public Health Aspects of Osteoarticular Diseases at the University of Liege, Belgium, also found that 74 studies met their criteria between 1994 and 2003, but that only 16 focused on total knee arthroplasty exclusively, and that the duration of follow-up ranged from 7 days to 7 years, with the majority describing results at 6-12 months. These small number of studies worldwide reported excellent outcomes within this optimal time frame. No studies were found that gave the patients and physicians data on the outcome past the expected life span of the prosthetics, which is generally accepted to be about 6-7 years with the first knee replacement. The study found that men seemed to benefit more than women, and that when improvement was found to be only modest, the researchers emphasized the role of comorbidities, or other health problems. The success of total knee replacement was found to exceed the success of other knee surgeries of standard procedures, which as mentioned above, did not fair so well in large studies in the long term. No studies are available to compare the success of conservative protocols to the total knee replacement. Apparently, no studies of outcomes after 2003 are available as well.

The patient must make a choice of going through a total knee replacement based upon incomplete and unclear industry study so far. These studies do summarize the procedures as highly successful. Many patients, though, are considering this scenario and exploring ways to utilize conservative care, mainly with Complementary Medicine, to try to reverse joint degeneration, or slow it, to avoid or delay the need for total knee replacement. Another consideration is the integration of conservative therapies after a total knee replacement, which could potentially speed recovery, increase functional imporovement, and prolong the health of the tissues around the prosthetic to delay the time when a second total knee replacement may be needed. If opting for use of Complementary Medicine before the need for the first total knee replacement, a large number of scientific studies now demonstrate proof that various strategies may result in growth of healthy cartilage and joint tissues. When considering a conservative treatment protocol, the patient should look to combine a sensible array of these therapies in a package of care. The choice of just trying one type of therapeutic intervention at a time is a prescription for failure. An intelligent combination of therapies within a protocol is the wise choice, and the patient should try to find the most knowledgable Complementary Medicine physician with an array of treatment skills to deliver this protocol. Combining physiotherapies, such as soft tissue mobilization and myofascial release, with acupuncture, electrical stimulation, evidence-based herbal and nutrient medicines, and patient instruction in self-administered therapies, such as postural and gait correction, and targeted stretch and exercise, is the formula for success.

Trust and Confidence: the need for the patient to take a realistic and objective assessment of the health care industry and influence on government when deciding the course of treatment

There is a history of enormous monetary intervention by the health care industry in both influencing government, and influencing the health care provider and public with treatment recommendations and data. The current health care debate has revealed that the health care industry accounts for over 15% of the entire economy, and could potentially account for up to 30% in the future. Of course, with this amount of profit as a motive, common business sense requires the industry to try to control how this enormous sum of money is spent. Lobbying and political contribution by the health, insurance and pharmaceutical industry accounts for over half the direct campaign donation to congress in 2008, and anaylysts report that a similar figure might be applied to lobbying money spent. Advertising budgets have soared, and the finance committee in the U.S. Senate, leg by Republican Charles Grassley, has uncovered massive amounts of money spent on fraudulent ghost-written scientific studies and payments to researchers and those who control university health research.

As published studies of efficacy in knee surgery emerged, there was a large decrease in the number of surgeries to repair degenerative knee joints. New devices, promising a more natural and “biologic’ approach to surgery, have emerged. In 2009, the FDA admitted that its own former commissioner unduly influenced the fast-track approval of such a device, a biologic meniscus patch, because of intense pressure from three Congressman and one Senator, all whom received significant campaign donations from the company manufacturing this device. The FDA agency director overrode the advice of its science advisors to approve and endorse this surgical device. The story can be read by clicking on the site in additional information at the end of this article.

Both the patient and the surgeon must not be unduly swayed by data and recommendations pushed by the industry, but must make a decision based on the realistic, safest and best course of therapy by analyzing objectively what could realistically work. Hopefully, this article helps the patient and their doctor decide to look into, and try conservative therapies. The course of therapy presented in Complementary Medicine is not simpler, and requires a proactive approach by the patient, but may produce the best long-term outcome for many patients.

Joint degeneration of the Lumbar vertebrae

A similar profile of degenerative joint conditions and unnecessary surgeries has been shown in large studies of lumbar spine pathologies. The New York Times article quotes Dr. Michael Modic, chairman of the Neurological Institute at the Cleveland Clinic, who scanned hundreds of study participants with MRI and concluded that as many as 60 percent of healthy adults with no back pain have degenerative conditions in their spines, and that between 20 and 25 percent that receive MRI studies of the lumbar have herniated or bulging discs. Dr. Modic states that one-third of these herniated or bulging discs disappear in six weeks when repeat MRI studies were performed, and about two-thirds disappear in six months. His study found no definitive correlation between worsening disc bulging, resolving disc bulging, and symptoms. He recommended that a person with low back and leg pain should be treated conservatively for at least eight weeks before considering surgery, and that MRI scans should be used as a presurgical tool, and not as a definitive diagnosis suggesting surgical correction.

Unfortunately, we live in a culture that wants a quick fix, and patients usually look at their situation as a choice between one type of therapeutic agent or regimen versus another. This will result in failure in the majority of cases. The successful approach utilizes a variety of agents and therapies to accomplish all 3 of the above goals, namely pain relief, elimination of the causes and contributors to tissue degeneration, and restoration of healthy tissues. By trying to choose a simplistic treatment approach, rather than a comprehensive treatment protocol, the patient is usually prolonging their suffering and at best will only slow the degenerative process. Surgery may be necessary, and may clean up some of the problems with unhealthy tissues, but without a comprehensive treatment plan, degenerative conditions will recur and continue to cause pain down the road.

In many patients, the same vascular pathology that worries them about risk of future cardiovascular problems also contributes to the spinal degenerative condition. In the medical text, Myelopathy, Radiculopathy, and Peripheral Entrapment Syndromes by David Durrant, and Jerome True, the authors state: “Many of the patients that develop degenerative stenosis fall into the same age group at risk for acquiring cardiac and peripheral vascular disease. Some of these individuals may also have a coagulation disorder from disease or from therapeutic intervention (blood thinners). Clinicians who identify cardiac, vertebral, and/or aortic diesase should pay attention to the possibility of a history suggestive of an undiagnosed intermittent myelopathic (spinal cord) presentation.” The arteries run alongside the nerve roots, spinal cord, and supply the needed nutrients to maintain the vertebral discs and lamina. Attention to vascular health should be part of the therapeutic protocol for degenerative lumbar conditions. An interesting area or research that links coagulation problems with fibrin buildup and hardening of both blood vessels and surrounding tissues, especially in the tight capillary beds of joints, is the subject of proteolytic enzymes. Nattokinase and serratiopeptidase are two especially potent proteolytic enzymes now studied to reduce microclotting and fibrous tissue formation. These supplements could significantly benefit the protocol in degenerative lumbar conditions, and perhaps improve vascular health and decrease atherosclerosis.

Much scientific research is devoted to understanding the underlying health problems leading to secondary osteoarthritis, or degenerative joint disease. The National Institutes of Health estimates that 18.2% of the U.S. population will have some form of arthritis or rheumatic condition by 2020. Osteoarthritis is the most common form of arthritis, affecting 12.1% of U.S. adults in 1998, and was the second most common diagnosis in the population. It is estimated that 80% of the aging population will experience secondary osteoarthritis. Research reveals that this slowly developing degenerative condition is likely related to a syndrome of anabolic dominance leading to an eventual catabolic excess. Anabolism is the metabolic construction of complex molecules in our tissue which is balanced with catabolism, the breaking down of complex molecules in the tissues to resupply energy and the building blocks of larger molecules. This process is stimulated and regulated mainly by hormones and the endocrine feedback system. In TCM terminology, this would be referred to as a balance of Yin and Yang, with anabolism being a yang process balanced by the bioavailability of catabolic yin nutrients and energy. When this balance is dysfunctional, a gradual disease process occurs leading eventually to Osteoarthritis.

The anabolic hormones include insulin and insulin-like growth factors, testosterone, estradiol, and growth hormone. When we have problems with hormonal balance and insulin resistance, or relative excess of estrogen from progesterone deficiency, we may develop anabolic dominance. Excess adrenal stress that is chronic may not only stimulate high blood pressure, but excess androgens and testosterone. Testosterone may aromatize to estradiol in our tissues, or to dehydroepiandosterone, and stimulate breast tumors, prostate hypertrophy, and other tissue abnormalities. In a similar way, these hormones play a significant role in tissue repair and maintenance, and imbalances may lead to degenerative arthritic conditions. Insulin resistance and anabolic dominance may lead to metabolic syndrome and inability to lose weight from the midsection, high cholesterol and poor cardiovascular maintenance. Such syndromes of imbalance lead to poor inflammatory regulation and tissue remodeling, and eventually degenerative joint disease is discovered, often too late to fully correct. The smart patient will seek help to prevent these problems be utilizing preventative medicine and TCM. The knowledgeable TCM physician can test for your hormonal profile, look at the circadian rhythms of cortisol imbalance, and gradually correct the Yin and Yang of hormonal imbalances that lead to degenerative disease. TCM may thus be a valuable Complementary Medicine in prevention of osteoarthritis as well as a comprehensive treatment strategy.

Hormonal health and the healthy production of anabolic growth factors appears to play an important role in all aspects of joint repair and regeneration. A 2012 study at the Department of Biomedical Engineering at Johns Hopkins University Medical Center, in Baltimore, Maryland (Li H, Feng F et al), found that a new type of drug, the matrix metalloproteinase (MMP) inhibitor, failed in early human clinical trials because the patients with osteoarthritis studied benefitted from the drug only in the presence of significant anabolic growth factors. Matrix metalloproteinase is enzyme that is zinc-dependent and plays an important role in tissue remodeling, with certain types of MMP in excess associated with both osteoarthritis and rheumatoid arthritis. Currently, drugs that inhibit MMP work by chelating zinc to decrease the enzyme activity. Since there are 28 known types of MMPs, many of which play important beneficial roles in the body, allopathic drugs to inhibit MMPs may be problematic concerning adverse effects. From such study, though, we may determine that an array of therapeutic protocols could potentially aid this aspect of joint tissue regeneration, such as hormonal balance, adrenal stimulation, chelation therapy, and improved regulation of inflammatory mediators, which are linked to excess MMP production, such as TNF-alpha and IL-1. This holistic approach holds much promise.

Another aspect of lumbar degeneration that has been well studied, but still stymies standard medical practice, is the degeneration of the lumbar discs. This type of degeneration is seen in a sigificant portion of the population even in the 30-40 year old range, and is expected in 60% of the aging population. Degenerative discs may range from mildly bulging to severe disc bulging with extrusions that are relatively large, and include stenosed, or flattened discs. Disc degeneration is not only reversible, but is proven in large studies, cited above, to reverse on its own in a high percentage of patients. MRI studies of degenerative discs can look quite alarming, with extrusions and bulges pressing into the surrounding joint tissues and even against the nerve roots and spinal cord. What is not seen in MRI studies is the fluid nature of many of these bulges and extrusions. Discs that are degenerated may bulge in different directions when body position changes the pressure on the disc, and extrusion may recede with change of body position. On the other hand, spinal disc herniations will usually stay stable no matter what the body position. The exact cause or causes of spinal disc degeneration still eludes science, although many studies do explain the array of factors seen with this pathology. The challenge for the physician and patient is to understand what course of therapeutic protocols will help reverese the disc degeneration and restore healthy disc material.

The spinal disc is composed of hard annular rings surrounding a soft fluid center, with the endplates of the disc, on the top and bottom, composed of a type of cartilage, and pressed agaist the vertebral joint cartilage, or bone covering. Most of the nutrients that pass into the inner layers of the annular rings, and the inner gel-like pulposa, comes from the vertebral bone cartilage, and this cartilage, which is the bone covering, gets its nutrient chemicals largely from the blood vessels in the vertebral bones. When the cartilage of the vertebrae degenerates, the supply of nutrient chemicals to the disc endplates, and thus to the inner disc, is greatly diminished. Therapy that restores vertebral cartilage, decreases mechanical pressure on the vertebrae and discs, increases circulation, and decreases chronic inflammation, will help restore the vertebral discs. This process is similar to the restoration of the degenerative knee joint.

Utilizing Complementary and Integrative Medicine in the treatment of degenerative joint pathologies

Achieving pain relief with medication does not mean that the degenerative condition is resolved, and when the patient focuses only on pain relief as a measure of success, this success is usually temporary. Dependence on pain relieving medication can be very harmful to the health and create other serious problems, such as stomach and gastrointestinal problems, and cardiovascular inflammation. A whole treatment protocol, directed by a competent physician, utilizing physiotherapy, patient instruction, acupuncture, herbal prescription, dietary supplements and changes, and correction of postural mechanics is effective, especially when the physician, who is a Licensed Acupuncturist, identifies contributing health problems and addresses these as well. The ultimate benefits of this comprehensive approach are many, and the patient will emerge with not only pain relief, but lasting tissue health, a healthier daily routine, and decreased risk of serious health problems related to aging.

An increasing array of scientific studies are demonstrating how acupuncture and electroacupuncture benefits patients with degenerative and rheumatic joint disease. Studies have consistently shown benefits on outcome studies with pain levels decreased and functional capacity increased over the last few decades with acupuncture, but this was often discounted by standard medicine as a placebo effect, or discounted for lack of double-blinding and use of an acupuncture placebo in human clinical trials, which is difficult, if not impossible to actually achieve. Studies in recent years have measured the chemical effects of acupuncture and electroacupuncture and found that remarkable benefits in clearing of pro-inflammatory cytokines, reactive oxygen species, and enzymes that drive degenerative joint disease are achieved. This is not a placebo effect. Some of these studies are cited below in additional information. When utilizing an array of proven therapeutic measures, such as electroacupuncture, acupuncture, Tui na physiotherapy, and herbal/nutrient medicine, the measured effects in the body to correct the inflammatory dysregulation, clear oxidant free radicals, and promote regrowth of healthy tissues, such as cartilage, are achievable. The combination of these therapies should be vastly superior to one protocol alone. This outcome, compared to standard medicine and the use of NSAIDS with adverse effects and no chance of promoting healthy regrowth, or the replacement of the joint with a prosthetic, with only a limited number of years of function, and a poor long-term outcome, is obviously superior. Finding the right Complementary Medicine physician, or knowledgeable Licensed Acupuncturist and herbalist, to deliver these effective treatments combined in an individualized treatment protocol, and provide quality researched medicinal herbs and nutriceuticals, is the key.

Popular supplements and herbs are frequently advertised with exaggerated claims and give the patients false hope. Prescription of herbal formulas and nutriceuticals by a Complementary Physician with a Medical License and education in herbal medicine, and utilizing professional products, will be much more effective. Along with the proper herbal formulas, acupuncture and physiotherapy, there are a variety of specific herbs and supplements of use. These products are usually helpful but are not a cure by themselves, and quality varies considerably between products due to the lack of regulation by the FDA. Professional products insure quality control, and these are available only to the Licensed herbalist. Here are the facts on some of the popular therapeutic aids available to the public:

Oral Glucosamine supplement: studies show that oral glucosamine had no effect of increasing glycosaminoglycan content when the cartilage was normal, but had some mild beneficial effect if the cartilage was in a rebuilding phase. Rebuilding cartilage has a much increased demand for glucosamine. Studies show that rates of collagen repair in the cartilage & meniscus were not affected by the amounts of oral glucosamine or injected glucosamine. These studies point to the fact that the patient must improve the body’s response to tissue repair in order to utilize the glucosamine supplement, and then this supplement will be effective. Thus, oral glucosamine, or glucosamine delivered locally to the tissue, in the form of topical agents or injections, will benefit only as part of a program that improves the overall tissue repair response. In patients that have no rebuilding of cartilage or meniscus, the glucosamine supplement is a waste of money. When the patient utilizes a complete conservative care treatment plan with passive soft tissue mobilization, gentle breaking up of tissue adhesions, and various stimulation techniques, the cartilage goes into a rebuilding phase, and the glucosamine is utilized fully (refer to PubMed PMID: 12355498)

Cartilage extracts with Matrix Proteins: sharks cartilage and bovine cartilage extracts have been available for some years, and are the principal sources for many chondroitin sulphate supplements. In many cases of degenerative joint problems, these have been ineffective. Studies that looked at patients with autoimmune cartilage diseases such as Rheumatoid Arthritis and Polymyalgia Rheumatica showed that these supplements could be useful to modify the course of the disease. The studies showed little effect in cases where the degeneration or joint inflammation was induced by medication side effect. The effectiveness of the cartilage protein extracts was linked to the immune stimulation of proteoglycan synthesis, and thus, concurrent use of immune stimulants or modifiers that enhanced interleukin or other cytotoxic immune response could greatly improve the effect. Once again, alone, these supplements may not benefit, but integrated logically into a treatment plan, they may have dramatic results for the right patients.

Collagen extracts and antioxidants: when the joint is receiving physiotherapy, with gentle breaking of chronic adhesions and improved circulation, there is a great need for large amounts of collagen in joint tissue repair. Studies show that the tissues may need up to 80 times the normal supply of collagen. Along with this nutrient material, antioxidants are required to help with clearing of dead tissues and debris. I use Health Concerns Collagenex 2 to supply usable collagen type 2 (glucosamine, chondroitin etc.) derived from compatible tissue extracts from the chicken, and delivered in a patented encapsulation discovered by many years of research at Harvard Medical College. The concurrent use of a potent tissue antioxidant supplement is also recommended, such as pomegranate extract. I also utilize a topical herbal cream that delivers glucosamine and chrondroitin with the carriers MSM and emu oil, so that these nutrients can get to the tissues directly. When used within the course of physiotherapy, this combination can benefit tissue repair greatly.

Hyaluronic acid injections: while hyaluronic acid (HLA) is utilized in injections for treatment of degenerated cartilage and joint tissues, these single injections are found to be of questionable value. HLA is a chemical in our cells that helps with cell hydration. A molecule of HLA may attract up to 1000 times its volume in water. Our cells create more HLA receptors when there is a problem with cell hydration, and HLA in circulation is proven to attach to receptors to help restore the hydration of dry cells. Dry cartilage cells are a primary problem in cartilage degeneration, and chondroitin sulfate produced by these cells also helps to retain water in the cartilage cells, or chondrocytes. Use of an HLA serum may supply needed hydration to these cells.

Hyaluronic acid or HLA/HA serum or capsules: Hyaluronic acid is a potent extracellular matric molecule that has a number of beneficial functions, including the adherence of fluid, and may bind up to 1000 times its molecular weight in water. HLA is found in many tissues, including cartilage, and is integral to cartilage health, function and repair. Much research has been conducted in recent years to deliver HLA to diseased and degenerative joints. HLA serum was developed to apply topically to the skin and shown to carry quickly to a large number of HLA receptors. An oral HLA delivery system was also developed, leading to promise in supplying the degenerative joint and cartilage with more HLA when needed. Study at such prestigious medical universities as Johns Hopkins has proven that this may be a significant aid to the overall protocol to restore cartilage. To see a link to this study, click here:http://www.ncbi.nlm.nih.gov/pubmed/22724901?dopt=Abstract

Maca and Cat's Claw: studies have shown significant benefit for cartilage repair with the use of these herbs. Of course, cartilage cells, or chondrocytes, will not regrow until manually stimulated. Studies have also shown that chondrocytes will regrow when the tissue is stimulated with gentle cross-fiber massage, or if this is not possible, with passive joint mobilization techniques and electrical stimulation. Studies showed enhanced mRNA (insulin like growth factor) expression and production in human chondrocytes when joint mobilization was utilized, and certain herbal chemicals have shown efficacy in promoting insulin like growth factor as well.

Gotu Kola: this herb has also demonstrated significant benefit in regrowth of joint tissues and cartilage. Chemicals act on collagen formation, anti-inflammatory activity, and antioxidant clearing. Amino acids and triterpenoids in Gotu Kola are considered to be essential to tissue healing. If there is a problem with varicosities or veinous insufficiency, combine this with Butcher's broom and Stone Root (Formula V).

Amino acids: certain amino acids are essential for repair of soft tissue such as ligament and tendons. L-Arginine, L-Lysine, L-Leucine and L-isoleucine are all effective, and should be combined with Vitamin B6 to increase utilization. The olympic swimmer Dara Torres claimed that an amino acid formula was extremely helpful in healing her tissues and helping her get to another Olympic tournament at age 41. Whey protein is a common source of amino acids.

Leucine amino acid plus Chinese herbs: a 2011 study, cited below, found that combining L-leucine with 3 standard Chinese herbs, Boswellia carterii (Gummi Olibanum, or Ru xiang, frankincense tree resin), Uncaria tomentosa (Gou teng, or Cat’s Claw in Peru), and Lepidium meyenii (Maca, or Lepidium micrathum, apetalum or latifolium in China, Ting li zi), exerted significant cartilage-protective and anti-inflammatory actions, switching cartilage cell (chondrocyte) gene expression from catabolic to anabolic pathways (destructive to regenerative). Prior studies found that Uncaria and Lepidium (Cat’s Claw and Maca) exerted a cartilage regenerating effect. The Chinese herbs Epimedium, or Yin yang huo, has also been proven in a number of studies to aid cartilage regeneration, and a variety of Chinese herbs traditionally used for arthritis are being studied at this time to prove efficacy as well. Lack of scientific studies is due to the cost of the process of staged in vivo and in vitro studies progressing to large double-blinded, placebo-controlled human clinical trials. Since the profit in herbal medicine is small, the field has not been able to duplicate the outrageously expensive clinical trial programs used in pharmaceutical medicine, and with thousands of years of clinical empirical evidence to support the herbal efficacy, was not considered a priority. These clinical trial programs often cost billions of dollars for new pharmaceuticals, but many experts state that these costs are inflated to justify the enormous prices of new pharmaceuticals. Herbal medicine, especially from China, is still devoted to the delivery of effective herbal medicines at a ridiculously low cost. The amino acid leucine is found in sunflower seed, watercress, soy, various fresh and dried beans, acacia, carob, fennel, coriander, cumin, taro, fava bean, pumpkin seed, and lentils. We see that a variety of cold-pressed fresh seed oils will deliver useful leucine, making pumpkin seed oil and unprocessed sunflower seed oil a healthy addition to the diet.

Boswellia and turmeric: Boswellia is the Chinese medicinal herb Ru xiang, olibanum gum, or boswellia carterii or serrata, commonly called frankincense tree resin. Frankincense is famous as one of the expensive offerings the Magi brought to the birth of Jesus, and at that time in history was a valuable trade commodity because of its amazing healing properties and use to quickly heal battle wounds. Turmeric, or curcumin, is also a Chinese medicinal herb. In fact three common Chinese medicinal herbs are curcumins, E zhu, Yu jin, and Jiang huang (turmeric), and are used to aid tissue repair, decrease inflammation, benefit circulation, help clear cancer and tissue growths, and aid the liver function. These herbs are now well studied in relation to cartilage growth and chronic inflammatory disease. Formulas, such as Back in Action from Vitamin Research Products, add nattokinase and DLPA (DL-phenylalanine) to form a more comprehensive treatment protocol in clearing the joint tissues, relieving pain, and aiding healthy regrowth. A study cited below, from the University of Liege, Belgium, states: “curcumin and structurally related biochemicals may become safer and more suitable nutraceutical alternatives to the non-steroidal anti-inflammatory drugs that are currently used for the treatment of osteoarthritis.” (Henrotin Y et al). These herbs have long been used in Chinese medicinal formulas to treat joint pathologies.

Manganese or Manganese SOD: manganese deficiency has been shown to be a significant factor in many cases of degenerative cartilage. Manganese deficiency results in the poor utilization of chondroitin, glucosamine and other mucopolysaccharides in the normal repair and maintenance of cartilage. Manganese SOD (super oxide dismutase) is a combination of a potent antioxidant with manganese, and thus may aid cartilage repair even more. Manganese is more commonly available in essential mineral supplements, some of which contain other nutrients beneficial to cartilage repair, such as Vitamin K (phytonadione), calcium hydroxyapatite, zinc monomethionine, and boron (Vitamin Research is a good professional source: Advanced Essential Minerals or Optimum D). Manganese SOD, or superoxide dismutase, is now difficult to find as a supplement. Concurrent use of a manganese supplement with an SOD source, such as dried barley sprouts, is recommended. Current research shows that angiotensin II, a protein that chronically stimulates higher blood pressure with adrenal hypertension, may both create more superoxide radicals and inhibit SOD in tissues. Treating adrenal stress syndrome may also be indirectly helpful for the healthy maintenance of degenerative tissues.

Proteolytic enzymes: Serratiopeptidase and Seaprose-S are two researched enzymes that help clear the rebuilding tissues and are proven to aid in both cartilage repair and decrease in chronic joint pain with a long course of use. Nattokinase is another heavily researched proteolytic enzyme that is becoming popular. A study (cited below) by the Pritzker School of Medicine of the University of Chicago, found in 1975 that enzyme treatment was an important factor in the responsiveness of cartilage cells, or chondrocytes, to stimulate greater production of chondrointin sulfate proteoglygan, or aggrecan.

Pomegranate extract with seed oil and polyphenol antioxidants enhanced by fermentation: a study by the Case Western Reserve University School of Medicine, published in the September 2005 issue of the Journal of Nutrition, demonstates that a properly prepared concentrated extract of pomegranate exherts significant antioxidant and anti-inflammatory properties, such as the inhibition of interleukin 1b, which plays a key role in cartilage degeneration in osteoarthritis. Polyphenols in whole pomegranate extract include anthocyanins, catechins, and punicalagins (a source of ellagic acid), which are now well studied and proven to be highly effective in many disease states other than tissue degeneration as well, such as cardiovascular disease, atherosclerosis, and cancer prevention. Use of this supplement will help to decrease the rate of cartilage degeneration, as well as speed growth of new healthy tissues by clearing oxidant radicals.

Procyanidin B3 in grape seed extract: study in 2011 at Keio University and Tokyo Medial and Dental University (cited below) showed that procyanidin B3 grape seed extract prevented cartilage destruction in animal studies. This was achieved in part through suppression of iNOS (inducible nitric oxide synthase), which is linked to the high expression of matrix metalloproteinases (MMPs) seen in osteoarthritis.

Boron and Vitamin D3: boron along with activated vitamin D3 hormone may increase cartilage formation. Boron helps regulate calcium metabolism and helps activate estrogen and vitamin D3, as well, preventing tissue calcification and aiding tissue repair. Food sources of boron include dates, raisins, prunes, almonds, hazelnuts and honey. Like many individuals, you may be deficient in activated vitamin D3, which is a hormone activated by exposure to sunlight on circulating D3. A simple blood stick test is available to determine D3 deficiency. Daily exposure to sunlight on the face and arms for 10 minutes insures activation, and so a midday walk in the sun is helpful. Exposure through glass in the car or office is not effective. You might take a cholecalciferol D3 supplement as well as chelated boron supplement combined with amino acids to aid utilization. Current study on boron supplementation is insufficient to definitively confirm that boron supplementation will treat arthritic conditons. Vitamin D3 is not really a vitamin, but rather a prohormone. D3 cholecalciferol is created daily in your body by exposure to sunlight, health cholesterol metabolism, and minimally from food sources. This cholecalciferol goes to the kidney to produce hormone D3. Two types of D3 hormone are known to science, and recent research has found that one isomer is integral to cartilage remodeling, regulating the basement membrane of the cartilage near the bone, and may be responsible for successful cartilage remodeling and repair. Since D3 hormone is tightly regulated in your body, not only supplementation with cholecalciferol and increased midday sun exposure is recommended, but also treatment to correct hormonal imbalances and improve the functions of the kidney and liver metabolism. Studies show that a high percentage of the population is deficient in D3. Utilize a holistic medical regimen to best advantage when taking these supplements. Deficiency of Vitamin D3 hormone is very widespread now in the United States, and could lead to a hormonal deficiency that affects the D3 hormone that regulates cartilage remodeling. Supplements with both D3 and boron are available. Coral 3X by Vitamin Research contains 1200IU cholecalciferol (Vitamin D3) plus 4mg of boron, with ascorbic acid (Vitamin C), calcium and a balanced array of minerals from coral, including magnesium, all of which may benefit joint tissue repair.

Information Resources

NY Times Health article on recent evidence supporting conservative care with meniscus tears http://www.nytimes.com/2008/12/09/health/09scan.html?partner=rss Environmental Health Perspectives gives a peer-reviewed in depth analysis of the benefits of boron supplement at http://www.ehponline.org/members/1994/Suppl-7/newnham-full.html An initial human clinical trial of purified extract from chicken cartilage showed that this supplement of Collagen type II of bioidentical form can reach the affected joint and both a decrease in autoimmune destruction and repair of the joint:http://chickencartilage.com/harvardstudy/ Serratiopeptidase is clearly explained athttp://www.purebodysolutions.com/Merchant2/graphics/00000001/PDF/serratiopeptidase.pdf Hyaluronic acid injections are not the same as prolotherapy; a large randomized trial in France was completed in 2008 and showed no benefits:http://www3.interscience.wiley.com/journal/122220639/abstract?CRETRY=1&SRETRY=0 A 2009 article in the New York Times outlines current research that shows that platelet-rich plasma injections found in rigorous study to provide no better healing than saline injections, and that steroid injections provide temporary benefit, but do not change long-term outcomes of pain and disability. : http://www.nytimes.com/2010/01/13/health/13tendon.html?ref=health A 2012 study of the effects of electroacupuncture to improve postoperative healing and recovery from total knee replacement, conducted at Wuhan Puai Hospital, Wuhan, China, showed that HSS scores, VAS pain scores, and functional measurements were markedly improved in the group receiving electroacupuncture combined with standard rehabilitation :http://www.ncbi.nlm.nih.gov/pubmed/22734376 A 2007 study at Chongqing Medical University in Chongqing, China, found that electroacupuncture and Chinese physiotherapy, or Tui na (called massage in translation), remarkably suppressed the pro-inflammatory cytokines interleukin-1beta (IL-1b) and TNF-alpha in the synovial membranes of arthritic joints, which is found to drive the degeneration seen in osteoarthritic knee joints: http://www.ncbi.nlm.nih.gov/pubmed/17650656 A 2008 study at Chongqing Medical University in Chongqing, China, found that electroacupuncture and Chinese physiotherapy, or Tui na (called massage in translation), also raised the beneficial antioxidant activity of super oxide dismutase (SOD) and lowered the reactive oxygen species (ROS) nitric oxide and malondiealdehyde (MDA) in knee joints affected by degenerative osteoarthritis: http://www.ncbi.nlm.nih.gov/pubmed/18630588 A 2001 study by the Univerisidad Nacional in Lima, Peru, demonstrate that Cat's Claw, or other species of Uncaria, had proven beneficial effects on human study participants with osteoarthritis of the knee, both reducing pain and with antioxidant and anti-inflammatory mechanisms, especially the inhibition of TNFalpha:http://www.ncbi.nlm.nih.gov/pubmed/11603848 A 2009 NY Times article reveals manipulation of FDA approval of new biologic surgical devices: http://www.nytimes.com/2009/09/25/health/policy/25knee.html A study in Japan, published in the Journal of Bone and Mineral Metabolism, found that AGEs (advanced glycation endproducts) were highly associated with osteoporotic vertebral microfractures in a large study of aging women:http://www.springerlink.com/content/3058213826n8404j/ A 1975 study at the Pritzker School of Medicine at the University of Chicago found that enzyme therapy was an essential cofactor of stimulation of increased chondroitin sulfate proteoglycan production by cartilage cells, or chondrocytes:http://informahealthcare.com/doi/abs/10.3109/03008207509152169 A 2011 study at Case Western Reserve University Department of Rhematology, in Cleveland, Ohio, found that a combination of the amino acid L-leucine with 3 standard Chinese herbs, Ru xiang (boswellia), Gou teng (Uncaria), and Ting li zi (Lepidium) reversed the destruction of cartilage (catabolic chondrocyte gene expression) to a regenerating pathway (anabolic chondrocyte expression), via both cartilage protective and anti-inflammatory mechanisms: http://www.ncbi.nlm.nih.gov/pubmed/21854562 A 2011 study at Laila Impex Research and Development in Vijayawada, India, found that boswellia extracts exhibit potent anti-inflammatory and anti-arthritic potential, aiding recovery of cartilage and protecting against proteolytic degradation in osteoarthritis and rheumatoid arthritis: http://www.ncbi.nlm.nih.gov/pubmed/21479939 A 2010 study at Cardiff University School of Biosciences, in the United Kingdom, found that boswellia extracts prevent collagen degeneration, inhibit inflammation, and has great potential as a treatment for arthritis and degenerative joint disease:http://www.ncbi.nlm.nih.gov/pubmed/19943332 A 2010 study at the University of Liege, Institute of Pathology, in Liege, Belgium, found that curcumin (turmeric, E zhu, Yu jin) protects cartilage cells (chondrocytes) from degeneration (catabolism) by inhibiting pro-inflammatory cytokines and other chemicals, and promoting chemicals, such as MMP-3 and caspase-3, that aid cartilage repair and regeneration:http://www.ncbi.nlm.nih.gov/pubmed/19836480 A 2012 study at Sichuan University in Chengdu, China, found that a chemical in the herb Epimedium, or Yin yang huo, icariin, accelerated cartilage growth, synthesis of glycosaminoglycans and collagen type 2: http://www.ncbi.nlm.nih.gov/pubmed/22308065 A 2011 study at Huazhong University of Science and Technology, and Hubei Key Laboratory of Natural Medicinal Chemistry, in Wuhan, China, found that the Chinese herb Arisaema (Xue li jian, or Dan nan xing) demonstrated significant anti-inflammatory and anti-arthritic activity, and suppressed the progression of collagen-induced arthritis:http://www.ncbi.nlm.nih.gov/pubmed/21029771 A 2010 study at Fujian University of Traditional Chinese Medicine (TCM), in Beijing, China, analyzed a common TCM formula used to treat or prevent osteoarthritis, Jingzhi Tougu Xiaotong Granule, and found that this formula of herbs delivered 514 known chemicals, many of which have therapeutic actions that target 35 beneficial chemical targets seen in pharmaceutical research. This shows the broad therapeutic potential of Chinese herbal formulas to deliver a thorough, holistic and effective treatment, covering all aspects of the disease mechanism. The herbs in this formula are: Morindae officianalis (Ba ji tian), Caulis sinomenii (Sinomenium acutum, or Fang ji, Stephania root), Paeoniae alba (Bai shao), and other typical anti-arthritic herbs:http://www.whxb.pku.edu.cn/EN/abstract/abstract26943.shtml A 2009 study at Fujian University of Traditional Chinese Medicine (TCM), in Beijing, China, analyzed a common TCM formula used to treat or prevent osteoarthritis, Jingzhi Tougu Xiaotong Granule, and found that this formula of herbs targeted inhibition of many important enzymes, especially MMP-3, related to joint degeneration, as well as pro-inflammatory cytokines, oxygen free radicals, and peptide radicals, potentially postponing degeneration of cartilage in osteoarthritis : http://www.ncbi.nlm.nih.gov/pubmed/19802542 A 2011 study at Keio University and Tokyo Medical and Dental University found that procyanidin B3 in grape seed extract significantly reduced cartilage degeneration, mainly through suppression of inducible nitric oxide synthase (iNOS), the main stimulant of excess matrix metalloproteinases (MMPs) seen in osteoarthritis : http://www.plosone.org/article/info A systematic review of 1151 clinical trials of non-steroidal anti-inflammatory drugs (NSAIDS), the only real allopathic medicine commonly prescribed for osteoarthritic degeneration and pain, by the esteemed Cochrane Database Systematic Review, found that there were consistent inadequecies in these studies. The array of studies from 1966 to 1995 utilized double-blinded placebo-controlled human trials, but only 22 were found that targeted osteoarthritis of the knee, and only 16 filled the criteria for a sound study. The study design in these trials was rated poor (3/8 on a scale of 1-8), and efficacy of specific NSAID medications was indeterminate, with a criteria being likelihood of withdrawal from the study due to lack of efficacy. Only 2 studies showed a statistically different effect in pain relief between NSAIDS, and in these trials the targeted NSAID, etolodac (Lodine) was prescribed in dosages 25-44 percent higher than the NSAID used as a comparative. The warnings for etolodac (Lodine) include increased risk of stroke or heart attack, gastric and intestinal bleeding, shortness of breath, unusual sweating, and changes in mental function:http://www.ncbi.nlm.nih.gov/pubmed/17636601

 

As people age, bone strength and muscle elasticity and tone tend to decrease. The discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae.  Spinal degeneration from disc wear and tear can lead to a narrowing of the spinal canal. A person with spinal degeneration may experience stiffness in the back upon awakening or may feel pain after walking or standing for a long time.


Under study for patients with degenerative disc disease is artificial spinal disc replacement surgery. The damaged disc is removed and a metal and plastic disc about the size of a quarter is inserted into the spine. Ideal candidates for disc replacement surgery are persons between the ages of 20 and 60 who have only one degenerating disc, do not have a systemic bone disease such as osteoporosis, have not had previous back surgery, and have failed to respond to other forms of nonsurgical treatment. Compared to other forms of back surgery, recovery from this form of surgery appears to be shorter and the procedure has fewer complications.

Understanding degenerative disc and joint disease

Degeneration of the intervertebral lumbar discs is a problem that nearly all of us will face, leading to a variety of scenarios of bulging and herniation. These degenerative disc pathologies may present with no symptoms to severe constant symptoms of pain, muscle weakness, numbness, paresthesia, and/or neurological dysesthesia. A wide variety of symptom presentations are seen clinically, oftened partially relieved with change of position, rest, or activity modification. The lower lumbar spine is the most common location for symptomatic disc herniation, accounting for nearly 80 percent of all disc herniations. The disc is a cushion between the large bodies of the vertebrae, and plays an important part in vertebral mobility as well as separation and positioning. The disc is composed of an outer ring of hard tissues, similar to ligament tissue, and an inner core that is more fluid, called the nucleus pulposa. It has no blood vessels, and nutrition of the disc depends upon fluid being pushed in and out of the disc, mainly through the intervertebral endplate. As we age, the inner pulposa of the disc gradually hardens, and mobility decreases. This also helps us as we age, though, as a fully hardened disc cannot bulge or herniate. Disc herniations and degenerative bulging commonly occur between the age of 30 to 50, when the disc still has a high fluidity. Bulging and herniation occur when the inner fluid pulposa pushes out through the harder layers of outer rings. The outer rings may experience small tears and degeneration, allowing the disc center to bulge, usually to the rear, as sitting and lumbar flexion opens the vertebrae this way. Prolonged sitting usually increases the pain with bulging discs. When the discs bulge to the rear and side of the vertebrae, the bulge may impinge upon the opening, or foramen, where the nerve root emerges. This is called positional impingment of the nerve root, or radiculopathy.

If the degenerative disc experiences sufficient trauma, the disc may herniate, meaning that the inner fluid pulposa sac emerges through a large tear, and usually causes a constant impingment if the herniation is posterior and lateral into the nerve root opening. Disc herniations may occur through the endplates or through the anulus fibrosum, or sides of the disc, usually through the posterior wall. Fragments of the disc may be contained or extruded, causing a variety of irritations of other tissues and nerve endings. The MRI will be very useful to diagnose these conditions, although bulging discs may not impinge as much when the patient is lying supine in the MRI machine. This is why newer MRI devices may examine the patient in a standing or moving position. Another problem that may eventually cause impingement upon the nerve root is disc narrowing, or stenosis. Sufficient disc height, or thickness, is needed to provide a sufficient space for the nerve root to exit the spinal cord. The discs need to rehydrate each day to maintain their height. This usually occurs when we sleep, but when tight muscles and tendons keep the lumbar vertebrae compressed at night, the discs may have trouble hydrating. Eventually, severe disc stenosis may lead to a sciatic pathology, or radiculopathy. Disc stenosis may also decrease joint mobility, contributing to degenerative joint disease. Therapy to release deep muscles and mobilize lumbar joints is often necesary to prevent or reverse these conditions.

Decades of research have still not identified the one physiological mechanism that causes degenerative disc disease. This is because a group of mechanisms is responsible. Allopathic medicine is still looking for the one type of surgical correction, or one drug, that will correct lumbar degenerative disease. The intelligent patient realizes that a more thorough and holistic approach is necessary. Inflammatory processes must become healthier, creating healthy new tissues, and clearing degenerative tissues. For this to be possible, increased circulation must be established. Deep stabilizing muscles must be released from chronic contracture if the circulation is to be restored. Chronic contracture will also add mechanical impingement with movement that wears down joint tissues. If postural habits have been acquired that contributes to muscle contracture and puts abnormal stress upon the lumbar joint tissues, these habits have to be corrected. A complete package of care is the sensible approach to restoration of healthy tissues at the lumbar. Research into inflammatory dysfunction is very useful to the herbalist as well. The more we learn about specific inflammatory dysfunction, the more we can apply specific herbal remedies to correct these problems.

Numerous studies have documented the matrix tissue degradation pathway in degenerative disc disease. The inflammatory mediators interleukin-1 beta (IL-1 beta) and TNFalpha have been shown to be overexpressed in degenerating discs, driving excess degradation enzymes. Novel antagonists of the IL-1 beta receptors have been created and tested in studies by the pharmaceutical industry, but side effects have made these drugs not well used at this time. The National Institute of Health (NIH) funded a study conducted at the University of Maryland Center for Integrative Medicine, with participation by Harvard Medical School and the University of Illinois at Chicago (Rui-Xin Zhang et al) in 2008, and found that a classic formula of Chinese Herbs, Boswellia carterii (ru xiang), Commiphora myrrha (mo yao), Angelica sinensis (dang gui), and Salvia miltiorrhiza (dan shen), modified with Notopterygium incisum (qiang huo), Paeonia lactiflora (chi shao), Corydalis yanhusuo (yan hu suo), Ligusticum chuanxiong (chuan xiong), Gentiana macrophylla (qin jiao), Cinnamomum cassia (gui zhi), and Glycyrrhiza uralensis (gan cao), effectively reduced IL-1 beta and TNFalpha in laboratory animals with induced arthritis. No observable adverse effects were noted, and with a 42 day course of treatment, the researchers concluded that the formula produces significant anti-arthritic effects by suppressing pro-inflammatory cytokines (Journal of Ethnopharmacology 121(2009) 366-371).

Besides inhibition of the inflammatory mediators that drive degeneration of the intervertebral discs and joint capsules, it has also been found that supplementation with the key nutrient chemicals needed to restore healthy tissue, and antioxidants that target joint tissues is very effective in treatment of arthritis and degenerative disc and joint disease. The nucleus pulposus, or fluid center, or the vertebral disc consists of collagen type 2 and proteoglycans, notably aggrecan, much like the tissues of the joint capsule and ligaments. Studies at Harvard Medical School have been completed utilizing specific extracts of collagen type 2 derived from chicken tissues that are bioidentical to human collagen. Human trials have been completed and signficant benefit has been proven utilizing this extract bound in a natural membrane so that it better survives digestion and is delivered to the joint tissues. An antioxidant that is proven very effective for joint tissues is derived from the whole pomegranate, and is rich in anthocyanins. These products complete a sensible course of therapy to achieve all the necessary goals in restoration of degenerative discs and joint capsules that cause sciatica, combining herbal formula, patented collagen type 2 extract, whole pomegranate extract, myofascial release, soft tissue mobilization, acupuncture, patient instruction in targeted therapies and correction of postural mechanics.

It is very important to obtain the right therapeutic products to achieve these goals. While pomegranate juice is beneficial, the chemicals extracted from the rind and calyx of the plant are what is needed to produce the desired effects. Many collagen extracts on the market are not made with the patented methods researched at Harvard. A professional herbalist can insure that the products used in therapy are the real thing, and medicinal products from professional herbal companies are sold through these physicians. Dependable quality is maintained for physicians who rely on this quality to get the results that they need in the clinic. Commercial products are often highly hyped in advertising and packaging, but the FDA does not enforce claims of quality and assurance of quantity in these products. When research proves effectiveness, and the patient does not see the positive results, the problem is probably the poor quality of the product.

Information Resources

In 2006 and 2007, German researchers found positive proof with blinded placebo studies comparing acupuncture to sham acupuncture and conventional therapy, that acupuncture provided more effective outcome. Thousands of patients were enrolled in these studies. These clinical trials and studies show that including acupuncture into the whole protocol is a smart choice: http://news.bbc.co.uk/2/hi/health/7011738.stm In the near future, various implants will be used in lumbar surgeries to promote bone and tissue growth that eventually replaces the implant. To insure that this process works well for you, decreasing mechanical stress with myofascial release and soft tissue mobilization, and promoting improved tissue healing with acupuncture and herbal/nutrient medicine is recommended. This protocol could result in a healthy spine for many patients with severe degenerative tissue problems in the future. Click here to review some of these promising surgical strategies: http://www.medscape.com/viewarticle/405701_2