rheumatoid arthritis

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Arthritis: herbs don’t help – says research

Arthritis: herbs don't help

Arthritis: herbs don’t help

“Many herbal medicines and other complementary therapies do nothing to help people with rheumatoid arthritis” The Guardian has reported. The news comes from a report by the Arthritis Research Campaign (ARC) that ranked the alternative and complementary therapies on their safety and effectiveness at treating arthritic conditions.

The report summarises the body of scientific evidence on 40 alternative treatments and scores their effectiveness and safety. One Chinese herbal medicine called “thunder god vine” was found to have serious side effects including nausea and hair loss, while nine treatments were reported to regularly cause side effects. Many treatments were also found to be ineffective or to have little evidence backing their anecdotal benefits.

According to the ARC almost half of arthritis sufferers turn to complementary medicines, spending more than £450m annually. Members of the public may be spending their money on ineffective treatments, and there remains a greater concern that they could be harming themselves or forgoing conventional treatments in the process. While herbal and complementary treatments may be derived from nature, the public should be aware that they still have the potential to cause harm.

Where did the story come from?

The report was commissioned by the ARC, a UK charity supporting research into arthritis and musculoskeletal conditions. The corresponding author was Professor Gary J Macfarlane from the University of Aberdeen School of Medicine and Dentistry. The study was published on the ARC website, and it is unclear whether the report has been peer reviewed.

What kind of scientific study was this?

This evidence-based review summarises evidence on the effectiveness and safety of several herbal and complementary medicines commonly used to treat arthritic conditions. These summaries were compiled into a single 80-page report, which features safety and effectiveness ratings for each treatment.

There are lots of compounds that have been proposed as treatments for rheumatoid arthritis, osteoarthritis and fibromyalgia, and the authors of the report aimed to identify all of those where there has been some claim supported by research evidence.

Specifically, the researchers were interested in compounds that were taken by mouth or applied to the skin. They excluded therapies such as acupuncture, chiropractic, massage and several other hands-on therapies that have been commonly used for arthritis and musculoskeletal conditions. The report covers forty complementary and alternative medicines including deer antler velvet, vitamins and willow bark.

These summaries were compiled by systematically searching medical and scientific literature on these popular alternative treatments. The study’s authors used experts in the field to search for and evaluate the evidence. As the report was aimed at the general public, it also included input from a patient representative.

The authors say that in herbalism emphasis is on an individualised approach, with patients receiving a tailored prescription. However, a recent review concluded that there was a scarcity of evidence regarding individualised herbal medicine and no convincing evidence to support its use. The authors did not search for reports of such an approach.

The authors relied heavily on the results of randomised trials and gave preference to this type of evidence  when estimating an effectiveness score. The scoring system assessed the quality of trials, appraised based on a scoring system called the “Jadad scoring scale”. This commonly used scale has levels from 1 (very poor quality) to 5 (very good quality). The researchers collapsed the scale into two categories: good/high quality (Jadad score 3 or above), and low quality (Jadad score below 3).

They took this into account when scoring the compounds’ overall research evidence base, defining the scores as follows:

1 – There is, overall, no evidence to suggest that the compound works or only a little evidence which is outweighed by much stronger evidence that it does not work.

2 – There is only a little evidence to suggest the compound might work. The evidence from studies in this category often came from only a single study which reported positive results. There are, therefore, important doubts about whether or not it works.

3 – There is some promising evidence to suggest that the compound works. The evidence will be from more than one study. However, there may also be some studies showing that it does not work. Therefore, we are still uncertain whether compounds in this category work or not.

4 – There is some consistency to the evidence, which will come from more than one study, to suggest that the compound works. Although there are still doubts from the evidence that it works, on balance, we feel that it is more likely to be effective than not.

5 – There is consistent evidence across several studies to suggest that this compound is effective.

The safety categories are based on a scheme developed by the authors:

Green “traffic light” was awarded to compounds with reported adverse effects which were mainly minor symptoms and infrequent. A classification of green does not mean that the compound has no reported adverse effects and patients should check in the product information leaflet what these are.

Amber “traffic light” was awarded to compounds with adverse effects reported as common (even if they were mainly minor symptoms) or with more serious adverse effects.

Red “traffic light” was awarded to compounds where serious adverse effects were reported. Patients should carefully consider these before deciding whether to take these medicines

What were the results of the study?

The ARC awarded just one point to 13 of the 21 complementary medicines for rheumatoid arthritis, suggesting that these compounds were not effective treatments. The ARC scored fish oils extracted from oily fish such as sardines, salmon and mackerel a maximum 5 points, suggesting they offer benefits. Fish oils also received a green light for safety.

For osteoarthritis three of 28 natural remedies were found to be supported by strong or moderate evidence. The most effective, capsaicin gel, (a therapy based on chilli peppers) has been shown to reduce pain among osteoarthritis patients. A herbal mixture called phytodolor and the nutritional supplement S-adenosyl-L-methionine (SAMe), both received 4 points for effectiveness.

Glucosamine, one of the most widely taken products, has featured in many trials. It was reported to be effective in some trials but not in others. The researchers found that the evidence was stronger for glucosamine sulphate (which scored 3) compared with glucosamine hydrochloride (which scored 1).

For fibromyalgia the researchers report that of the four products assessed, none was highly effective, with three medicines scoring 2 points out of 5, and the fourth considered ineffective, scoring just 1 point.

What interpretations did the researchers draw from these results?

The researchers say that more information on the research studies is available in their full report. In terms of safety, the authors conclude that there is much less information available on complementary medicines than on conventional pharmaceutical medicines.

The researchers gave nine of the compounds an amber safety classification, indicating there were important side effects which had been reported, or that there was insufficient evidence to make a judgement. The “red” safety classification was only issued against the traditional Chinese herbal extract “thunder god vine”.

What does the NHS Knowledge Service make of this study?

This review of the evidence regarding complementary and alternative medicines will undoubtedly be of interest to many people living with painful or debilitating arthritic conditions. The full report clearly presents the results for each compound in a structured way, allowing the public to understand the scientific basis (or lack of one) behind a range of alternative treatments.

The authors acknowledge limitations, in terms of not being able to include emerging evidence and scientific studies published since their search. They say that research that could not be appraised in time for publication will be addressed in future updates.

Given the nature of chronic conditions such as arthritis, people may attempt to manage their symptoms or pain by regularly using complementary treatments. This review highlights the fact that many complementary medicines may not have been subjected to the rigorous safety and effectiveness tests that pharmaceutical products must undergo.

In turn this illustrates that many people may be purchasing treatments that have little or no proven benefit. While this can be financially costly, there is the greater hazard that people may be harming themselves by using untested substances. In fact, one-quarter of treatments tested were found to have common or serious side effects.

While members of the public may continue to choose to use complimentary medicines, they should be aware that there are potential dangers, that conventional treatments available through a GP may be free and that these treatments will have been tested for both their safety and effectiveness.

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Joint pain – signs, symptoms and causes

Joint Pain

Joint Pain

Introduction

Joint pain is a very common problem with many possible causes – but it’s usually a result of injury or arthritis.

In older people, joint pain that gets steadily worse is usually a sign of osteoarthritis. It may affect just one joint, or many. See your GP if you have persistent symptoms of osteoarthritis.

The information and advice on this page shouldn’t be used to self-diagnose your condition, but may give you a better idea of what’s causing your pain.

 

Knee pain

The knee joint is probably the most frequently damaged joint and is particularly vulnerable as it takes the full weight of your body.

However, knee pain isn’t always a joint problem. Learn about the most common causes of knee pain and what you should do.

The most common and more unusual causes of pain in a single joint are described below.

Inflammation of the joint lining

If you’ve injured the joint recently and it suddenly becomes painful again, the thin layer of tissue lining the joints and tendons may be inflamed – a condition called traumatic synovitis. It usually doesn’t cause any redness or heat.

You should be able to manage injury-related swelling at home with anti-inflammatories, an icepack and rest.

Gout or pseudogout

If the skin over the joint is hot and red, and the pain comes in repeated attacks, the cause is likely to be either gout or pseudogout.

Both conditions are types of arthritis.

Gout usually affects the joint of the big toe first, before affecting other joints. It’s important to correctly diagnose gout, as treatment will prevent future attacks of joint pain and disability.

Pseudogout is a similar condition to gout, but usually affects the knee joint first.

See your GP if you think you have either condition.

Damage to the cartilage at the back of the kneecap

Knee pain that feels worse when going up or down stairs could be a sign of a damaged kneecap – a condition called chondromalacia patellae. This shouldn’t cause any redness or heat around the knee.

The cause isn’t really understood, but it can be linked to overuse of the knee.

You can treat this problem yourself with anti-inflammatories, an icepack and rest.

Bleeding into the joint space

If you’ve recently had an injury to the knee joint, such as a torn ligament or knee fracture, it may cause bleeding into the joint spaces. This is known as haemarthrosis.

This is more likely to happen to people on anticoagulants, such as warfarin.

Signs of haemarthrosis are:

swelling of the knee

warmth

stiffness and bruising, which occur soon after the injury

You should go to hospital immediately for treatment if you have a very swollen knee.

Less common causes

Sudden pain in a joint is less commonly caused by:

a fracture – read about a broken arm or wrist, broken leg, broken ankle or hip fracture

reactive arthritis – which usually develops after an infection and tends to affect young adults

psoriatic arthritis – a type of arthritis that affects up to one in five people with psoriasis

rheumatoid arthritis – which can start in just one joint, with the pain coming and going

Osgood-Schlatter’s disease – swelling and tenderness over the bony bump just below the kneecap

Rarely, the cause may be:

septic arthritis – a serious condition that causes a painful, hot, swollen joint that you won’t be able to move (sometimes with fever) – see your GP urgently or go to A&E

haemophilia – an inherited condition that affects the blood’s ability to clot

a tropical infection

cancer

crumbling of the bone (avascular necrosis) – caused by a lack of blood supply

repeated dislocation of the joint

Pain in many joints

Rheumatoid arthritis

Rheumatoid arthritis is another type of arthritis that causes pain and swelling in the joints – usually the hands, feet and wrists.

The pain may come and go in the early phases, with long periods between attacks.

It can leave you feeling generally unwell and tired. Read more about the symptoms of rheumatoid arthritis.

Psoriatic arthritis

Psoriatic arthritis affects up to one in five people with psoriasis. This type of arthritis is unpredictable, but flare-ups can usually be managed with treatment.

Like other types of arthritis, it means that one or more of your joints are inflamed and become swollen, stiff, painful and difficult to move.

A viral infection that causes arthritis

Examples of viral infections which can cause pain in the joints and symptoms of a fever include:

viral hepatitis – liver inflammation caused by a virus

rubella – a viral infection that used to be common in children

A disease of the connective tissue

Widespread joint pain is sometimes a sign of a disease that affects almost all the organs of the body, such as:

lupus – where the immune system mistakenly attacks healthy cells, tissue and organs

scleroderma – where the immune system attacks connective tissue underneath the skin, causing hard, thickened areas of skin

Less common causes

Widespread joint pain can less commonly be caused by:

a rarer type of arthritis – such as ankylosing spondylitis, juvenile arthritis or reactive arthritis

Behçet’s syndrome – a rare and poorly understood condition that causes inflammation of the blood vessels

Henoch-Schönlein purpura – a rare condition, usually seen in children, that causes blood vessels to become inflamed

cancer

some treatments – including steroid therapy, isoniazid and hydralazine

hypertrophic pulmonary osteoarthropathy – a rare disorder that causes clubbing of the fingers, seen in people with lung cancer

sarcoidosis – a rare condition that causes small patches of tissue to develop in the organs

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Want to avoid arthritis? Then brush your teeth – Gum disease bug linked to rheumatoid arthritis

Rheumatoid arthritis and tooth brushing

Rheumatoid arthritis and tooth brushing

“Want to avoid arthritis? Then brush your teeth . bugs that cause gum infections also trigger the crippling joint pain,” the Mail Online reports.

Rheumatoid arthritis is an autoimmune disease where the immune system attacks the cells that line joints by mistake. Exactly what causes this response is still unclear.

This latest study aimed to examine whether rheumatoid arthritis could have a possible bacterial cause, and whether these bacteria could come from the mouth.

Researchers examined gum fluid of people with gum disease (periodontitis) and found it contained high levels of what are known as citrullinated proteins. These are a type of protein known to trigger an immune response in people with rheumatoid arthritis.

Researchers also found evidence that a strain of bacteria called Aggregatibacter actinomycetemcomitans (A?) seemed to be causing these high levels of citrullinated proteins.

However, this doesn’t provide the whole answer to the rheumatoid arthritis puzzle. Not everyone with rheumatoid arthritis has an immune response to the citrullinated proteins. And conversely not everyone with this immune response had symptoms of rheumatoid arthritis.

Similarly, not everyone with gum disease develops rheumatoid arthritis, and vice versa.

Still, despite all of these uncertainties, regularly brushing your teeth is always a good idea. Gum disease may be linked with many other health complications, including stroke, diabetes and heart disease. Read more about the health risks of gum disease.

 

Where did the story come from?

The study was carried out by researchers from Johns Hopkins University School of Medicine and various other institutions in the US, and Aarhus University in Denmark. Individual researchers report several sources of financial support, including the Jerome L. Greene Foundation, the Donald B. and Dorothy L. Stabler Foundation, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases.

The study was published in the peer-reviewed journal Science Translational Medicine.

The Mail Online’s take on the research is arguably overly simplistic. The research does not prove that if you brush your teeth you will stop yourself getting “arthritis”, or that people with arthritis have had poor dental hygiene. The findings are very unlikely to provide the whole answer to the causes of rheumatoid arthritis – and rheumatoid arthritis is only one type of arthritis.

 

What kind of research was this?

This was a laboratory study which aimed to look into a possible bacterial cause of rheumatoid arthritis.

Rheumatoid arthritis is an autoimmune condition where the body’s immune cells attack the joints (often starting with the small joints of the hands and feet) causing inflammation, swelling, pain and stiffness. Although there are some known risk factors for rheumatoid arthritis, such as smoking, the causes aren’t established.

Researchers say that some recent studies have suggested mucosal surfaces in the body, like those in the gums, digestive system or lungs, could be the origin of the disease process. In particular they say that periodontitis – a bacterial inflammatory disease of the gums – has often been observed in people with rheumatoid arthritis and could be the start of the autoimmune, inflammatory process.

The study aimed to look into this question further.

 

What did the researchers do?

The researchers collected blood samples from 109 people with periodontitis and 100 healthy controls. They obtained samples of fluid from the space between the gums and teeth (gingival crevicular fluid) from nine of the people with periodontitis and eight controls.

They also identified another sample of 196 people who met standard disease criteria for rheumatoid arthritis, from whom they obtained blood and joint fluid samples.

The researchers analysed the gum fluid in the laboratory to look at its composition and see how it differed between controls and people with gum disease. They also looked at what similarities there were to the blood and joint fluid samples of people with rheumatoid arthritis.

 

What did they find?

The researchers found that the gum fluid of people with periodontitis reflected the inflammatory environment of the rheumatoid arthritis joint. There were extensive citrullinated proteins in the fluid, and people with rheumatoid arthritis are often found to produce antibodies against these proteins. The antibodies are known as anti-cyclic citrullinated peptides (anti-CCP).

By comparison, healthy people had minimal citrullinated proteins in their gum fluid.

When researchers conducted analysis to see what could be causing these high citrullinated proteins, they found several potential groups of bacteria, but one single bacterial species called Aggregatibacter actinomycetemcomitans (A?) emerged as the most likely candidate.

A? causes high production of citrullinated proteins within a particular type of white blood cell (neutrophil). It does this by producing a toxin called leukotoxin A (LtxA). This toxin splits open neutrophil cells which releases citrullinated proteins.

The researchers found that the citrullinated proteins in the gum fluid showed marked overlap with those found in the joint fluid of people with rheumatoid arthritis, with 44 of 86 proteins in common.

They also found that in people with rheumatoid arthritis, antibodies specifically targeting LtxA were found to be associated with the presence of anti-CCP antibodies.

 

What did the researchers conclude?

The researchers conclude: “These studies identify the periodontal pathogen A? as a candidate bacterial trigger of autoimmunity in rheumatoid arthritis”.

 

Conclusions

This research aimed to investigate a possible bacterial origin of rheumatoid arthritis and found one potential candidate – Aggregatibacter actinomycetemcomitans (A?). It seems these bacteria could cause the high levels of citrullinated proteins which are known to trigger an immune reaction in people with rheumatoid arthritis.

However, it’s important to put these findings into the right context.

Though antibodies against citrullinated proteins, anti-cyclic citrullinated peptide (anti-CCP), are one of the possible diagnostic findings in people with rheumatoid arthritis – not everyone with rheumatoid arthritis has these antibodies, and not everyone with these antibodies has rheumatoid arthritis. These are not an exclusive, defining hallmark of the disease. Therefore this will not provide the whole answer to the disease process.

Even if high citrullinated proteins were the single defining hallmark of rheumatoid arthritis, we still don’t know that the A? bacteria provide the whole answer to what causes this. There may be other infective and inflammatory processes contributing to the raised levels of these cellular proteins.

Care must also be taken when linking “arthritis” with dental care, as the media has done.

Not everyone with gum disease develops rheumatoid arthritis, and not everyone with rheumatoid arthritis has had previous gum disease or poor dental hygiene. There is nothing to say that the mouth is the one source of any potential causative infective process.

Overall, the findings are of interest and give further understanding of the potential causes of autoimmune disease processes like rheumatoid arthritis, which currently have no established cause. However, there are no immediate preventative or treatment implications.

Regularly brushing your teeth can help prevent a whole range of unpleasant conditions, such as tooth decay, toothache and gum diseases. But it cannot be said with confidence at this time that brushing can also prevent rheumatoid arthritis.

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Rheumatoid arthritis – what are the complications of Rheumatoid arthritis?

Rheumatoid arthritis

Rheumatoid arthritis can put you at a higher risk of developing other conditions, particularly if it’s not well controlled.

Some of these conditions are described below.

Carpal tunnel syndrome

Carpal tunnel syndrome is a common condition in people with rheumatoid arthritis.

It’s the result of compression of the nerve that controls sensation and movement in the hands (median nerve) and can cause symptoms such as:

aching

numbness

tingling in your thumb, fingers and part of the hand

Symptoms of carpal tunnel syndrome can sometimes be controlled with wrist splints or corticosteroid injections, although surgery to release the pressure on the median nerve may be needed in severe cases.

Read about treating carpal tunnel syndrome.

Widespread inflammation

Rheumatoid arthritis is an inflammatory condition which can cause inflammation to develop in other parts of your body, such as the:

Lungs – inflammation of the lungs or lung lining can lead to pleurisy or pulmonary fibrosis, which can cause chest pain, a persistent cough and shortness of breath.

Heart – inflammation of the tissue around the heart can lead to pericarditis, which causes chest pain.

Eyes – inflammation of the eyes can lead to scleritis or Sjogren’s syndrome. Scleritis can cause eye redness and pain, whereas Sjogren’s syndrome can cause dry eyes.

Blood vessels – known as vasculitis – this can lead to the thickening, weakening, narrowing and scarring of blood vessel walls. In serious cases, it can affect blood flow to your body’s organs and tissues and can be life-threatening.

However, thanks to early treatment, inflammation due to rheumatoid arthritis affecting other parts of the body is becoming less common.

Joint damage

If rheumatoid arthritis isn’t treated early or isn’t well controlled, the inflammation in your joints could lead to significant and permanent damage.

Problems that can affect the joints include:

damage to nearby bone and cartilage (a tough, flexible tissue that covers the surface of joints)

damage to nearby tendons (flexible tissue that attach muscle to bone), which could cause them to break (rupture)

joint deformities

These problems sometimes need to be treated with surgery to prevent loss of function in the affected joints.

Cardiovascular disease

If you have rheumatoid arthritis, you’re at a higher risk of developing cardiovascular disease (CVD) than the population at large.

CVD is a general term that describes conditions affecting the heart or blood vessels, and it includes life-threatening problems such as heart attacks and strokes.

It’s not clear exactly why people with rheumatoid arthritis are at an increased risk of these problems. You can reduce your risk by ensuring your arthritis is well controlled and by reducing the impact of other factors that contribute to CVD, such as:

stopping smoking

eating healthily

exercising regularly

Read about preventing CVD.

Cervical myelopathy

If you’ve had rheumatoid arthritis for some time, you’re at increased risk of developing cervical myelopathy and you may need a special assessment of your neck before any operation where you’re put to sleep.

This condition is caused by dislocation of join