From The January 1999 Issue of Nutrition Science News
By Cynthia Cooper, R.Ph
Relieving lingering musculoskeletal pain may be as straightforward as A, C and E
Pain is a unique biological process that is perceived differently by each person. Although the experience may vary, one thing is certainthe pain associated with osteoarthritis and rheumatoid arthritis has no simple antidote. People with chronic joint pain typically learn to live with the discomfort.
All arthritis involves the progressive degeneration of normal joints. Osteoarthritis is most often a function of wear and tear and age and is nearly universal in its appearance in all animals that possess bony skeletons. Interestingly, osteoarthritis does not occur in bats and sloths, two species that spend the majority of their lives hanging upside down, which reduces weight-bearing pressure on joints.
The erosion of the cartilage lining the joints is a hallmark of osteoarthritis. Proteoglycan, a mucopolysaccharide building block of cartilage within the joint space, is used by chondrocytes (cartilage-building cells) to create more cartilage. Over time, the chondrocytes' function may be thwarted by a scarcity of proteoglycan. Cartilage repair is compromised, bone is used instead to repair normal "micro" fractures created by weight-bearing activities, and an overall decrease in joint movement results. Eventually, the joints become stiffer and cause pain whenever they are used.
Rheumatoid arthritis is an immune system disorder that affects the joints and is most commonly seen in women. The synovial membranes lining the joints are colonized and attacked by the immune system's lymphocytes and plasma cells. The synovial cells respond by thickening and releasing substances, including prostaglandins, that compromise joint function and create pain within the joint.
Osteo- and rheumatoid arthritis pain differs from acute pain or injury in that arthritis pain is often insidious, becoming gradually more painful (although it sometimes occurs suddenly as well). Arthritis pain is also more complex because it may involve several foci of pain, affecting several joints. Additionally, the mechanisms of osteo- and rheumatoid arthritis pain may require different approaches to reliefthe causes must be alleviated along with the pain itself.
Natural Pain Relief
Unlike aspirin and other nonsteroidal, anti-inflammatory drugs commonly recommended for arthritis, natural remedies do more than mask painful symptoms. Antioxidants, fatty acids and enzymes target arthritis where it hurtsby protecting and repairing cartilage and reducing inflammation.
Glucosamine and chondroitin sulfates are partners in the process of regenerating cartilage, which reduces the pain and inflammation of osteoarthritis.
Vitamin D: Scientific studies are beginning to demonstrate that vitamin D helps slow the development of osteoarthritis. Researchers at Boston University Medical Center examined the knees of 556 patients during a two-year period.  Those patients who showed progressive knee damage due to osteoarthritis also exhibited lower levels of vitamin D. "A vitamin D deficiency could impair the body's ability to repair the damage that arthritis causes in both bone and cartilage," says David Felson, a principal investigator in the study.
Antioxidants: The antioxidant vitamins A, C and E and the mineral selenium are regularly touted as free radical scavengers. Free radicals are unstable molecules with missing or extra electrons that attack tissue such as cartilage or joint tissue in search of stabilizing electrons. The antioxidants scavenge or stabilize free radicals and, if present in sufficient quantities, can help prevent free radical-induced tissue damage and resulting inflammation.
A high intake of antioxidants, especially vitamin C, may reduce the risk of cartilage loss and slow the progression of osteoarthritis. Participants in the Framingham Osteoarthritis Cohort Study who took higher than average amounts of vitamin C had a threefold decrease in the risk of osteoarthritis.  Vitamin C, like vitamin E, also protects and enhances cartilage formation. Guinea pigs with experimental osteoarthritis given 150 mg daily of vitamin C demonstrated significantly less cartilage erosion than animals given only 24 mg vitamin C. 
Boron, though not an antioxidant, does prevent cells from releasing free radicals. Epidemiologic studies show that people in countries with low amounts of boron in the soil often have osteoarthritis.  Conversely, boron supplementation may encourage cartilage repair and synthesis. One open trial demonstrated that boron supplementation of 69 mg daily caused symptom remission in 90 percent of arthritis patients studied including people with osteoarthritis, rheumatoid arthritis and juvenile arthritis. 
Essential fatty acids: The joint inflammation that accompanies osteoarthritis is regulated in large part by essential fatty acids. The kinds of fat in the diet, particularly the ratio of omega-3 to omega-6 fatty acids, can either promote or hinder production of prostaglandins, the messenger molecules that influence pain and inflammation. The omega-3 fatty acids alpha-linoleic acid (ALA) and eicosapentaenoic acid (EPA) both decrease the production of pro-inflammatory prostaglandins, while gamma-linoleic acid (GLA) helps produce beneficial prostaglandins. Conversely, animal products and saturated fats in the diet ultimately produce arachidonic acid, a prostaglandin precursor that prompts inflammation and pain.
The omega-3 fatty acids are also touted by Harvard Medical School in Cambridge, Mass., as an effective tool for lessening the symptoms of rheumatoid arthritis. [6, 7]
An ideal omega-3 to omega-6 ratio ranges from 1:1 to 1:2. Most Americans, however, eat a diet that contains a ratio closer to 1:10 to 1:25. Eating more cold-water, fatty ocean fish such mackerel, herring, salmon, sardines and tuna remedies low EPA levels. GLA is present in evening primrose oil, black currant oil and borage seed oil, while green vegetables are a good source of ALA.
Bioflavonoids: The plant-derived bioflavonoids, often found in combination with vitamin C, have strong antioxidant and anti-inflammatory properties and appear to modulate key enzyme reactions in the inflammatory cascade.  Bioflavonoids also affect the structure of collagenthe strong fibrous protein found in all connective tissue including cartilageby protecting it from free radical destruction and cross-linking directly with the collagen fibers. 
Bioflavonoids are found in green tea, citrus fruit, berries, onions and pitted fruits. Supplemental forms include rutin, quercetin, hesperidin, ginkgo (Ginkgo biloba), milk thistle (Silybum marianum) and proanthocyanidins.
Glucosamine and chondroitin:
Glucosamine, a combination of glucose and the amino acid glutamine, furnishes the basic building blocks of mucopolysaccharides such as glucosaminoglycans (GAGs) and proteoglycans that form the framework of bones, cartilage, nails, hair and skin. Increased amounts of glucosamine stimulate the activity of specialized cells called chondrocytes. These cells then build a framework of bone and cartilage with mucopolysaccharides.
Chondroitin sulfates act as bait, attracting fluid into the weblike cartilage that covers the bones of the joint. The fluid attracted into the cartilage provides shock absorption for surrounding bones and supplies nutrients to the cartilage, thus supporting its regeneration and growth. Joint cartilage does not possess a blood supply, so its nutritional needs must be met by the fluid surrounding the joint.
Although glucosamine is common in most foods, supplemental sources of glucosamine are just as useful. Four forms of glucosamine are available as supplementshydrochloride, hydroiodide, n-acetyl and sulfatebut glucosamine sulfate has been studied the most. Chondroitins are available in animal tissues such as meat gristle. Supplemental chondroitin sulfates are absorbed by the body, but to a lesser extent than glucosamine sulfate because of their large size. They do not produce toxic side effects in high doses.
Enzymes: Bromelain is a mainstay for treating muscle injuries, but its anti-inflammatory actions may also ease arthritic pain. The proteolytic enzymes obtained from the stem of the pineapple plant (Ananas comosus) break down scar tissue, decrease edema and block inflammatory mediators.  In addition, when antioxidant enzyme superoxide dismutase (SOD) was injected into arthritic joints, it also had significant therapeutic effects . Oral doses are less likely to work.
Why Natural May Be Better
The process that contributes to osteoarthritis and results in chronic pain for millions of people ironically has the potential to be stopped and, in many cases, reversed. Researchers following the natural course of osteoarthritis found that 14 of 31 people with untreated osteoarthritic hips experienced complete recovery.  These and other similar results suggest that medical intervention may actually speed the disease along. Aspirin and other nonsteroidal anti-inflammatory drugs such as ibuprofen can not only trigger well-known side effects including gastrointestinal upset, headaches and dizziness, but studies show that they also inhibit cartilage synthesis and speed its destruction.  The very drugs designed to alleviate osteoarthritic pain may actually contribute to the diseasethe drawback to treating symptoms and not the cause.
The Cellular Origins of Pain
Cynthia Cooper, R.Ph., is a practicing pharmacist and a freelance writer in Boulder, Colo.
1. Felson D. Relation of dietary intake and serum levels of vitamin D to progression of osteoarthritis of the knee among participants in the Framingham Study. Ann Int Med 1996;125:353.
2. McAlindon TE, et al. Do antioxidant micronutrients protect against the development and progression of knee osteoarthritis? Arthritis Rheum 1996;39:648-56.
3. Schwartz ER. The modulation of osteoarthritic development by vitamins C and E. Int J Vitam Nutr Res 1984;26:141-6.
4. de Fabio A. Treatment and prevention of osteoarthritis. Townsend Letter for Doctors 1990 Feb-Mar:143-8.
5. Newnham RE. Arthritis or skeletal fluorosis and boron. Int Clin Nutr Rev 1991;11:68-70.
6. Anonymous. Harvard Health Letter 1993;18(9):4-5.
7. Anonymous. Harvard Health Letter 1996;21(11):8.
8. Tixer J, et al. Evidence by in vivo studies that binding of pycnogenols to elastin affects its rate of degradation by elastases. Biochem Pharmacol 1984;33(24):3933-9.
9. Rao C, et al. Influence of bioflavonoids on the metabolism and cross linking of collagen. Italian J Biochem 1981;30:259-70.
10. Ako H, et al. Isolation of a fibrinolysis enzyme activator from commercial bromelain. Arch Int Pharmacodynamics 1981;254:157-67.
11. Huskisson EC, Scott J. Orgotein in osteoarthritis of the knee joint. Eur J Rheumatol Inflamm 1981;4:212.
12. Perry GH, Smith MJG. Spontaneous recovery of the hip joint space in degenerative hip disease. Ann Rheum Dis 1972;31:440-8.
13. Sheild MJ. Anti-inflammatory drugs and their effects on cartilage synthesis and renal function. Eur J Rheumatol Inflamm 1993;13:7-16
Return to GLUCOSAMINE
Return to PAIN AND NUTRITION
Return to DEGENERATIVE JOINT DISEASE