Phyto-anti-inflammatories. A systematic review of randomized, placebo-controlled, double-blind trials

From Bush Medicine to Modern Phytopharmaceutical: A Bibliographic Review of Devil's Claw (Harpagophytum spp.)

Devil's claw (Harpagophytum spp., Pedaliaceae) is one of the best-documented phytomedicines. Its mode of action is largely elucidated, and its efficacy and excellent safety profile have been demonstrated in a long list of clinical investigations. The author conducted a bibliographic review which not only included peer-reviewed papers published in scientific journals but also a vast amount of grey literature, such as theses and reports initiated by governmental as well as non-governmental organizations, thus allowing for a more holistic presentation of the available evidence. Close to 700 sources published over the course of two centuries were identified, confirmed, and cataloged. The purpose of the review is three-fold: to trace the historical milestones in devil's claw becoming a modern herbal medicine, to point out gaps in the seemingly all-encompassing body of research, and to provide the reader with a reliable and comprehensive bibliography. The review covers aspects of ethnobotany, taxonomy, history of product development and commercialization, chemistry, pharmacology, toxicology, as well as clinical efficacy and safety. It is concluded that three areas stand out in need of further investigation. The taxonomical assessment of the genus is outdated and lacking. A revision is needed to account for intra- and inter-specific, geographical, and chemo-taxonomical variation, including variation in composition. Further research is needed to conclusively elucidate the active compound(s). Confounded by early substitution, intermixture, and blending, it has yet to be demonstrated beyond a reasonable doubt that both (or all) Harpagophytum spp. are equally (and interchangeably) safe and efficacious in clinical practice.

Complementary and Alternative Modalities (CAM) for pain management in musculoskeletal diseases (MSDs)

Musculoskeletal diseases are a group of clinical conditions affecting the body's movement and remain a common source of pain affecting the quality of life. The aetio-pathological reasons for pain associated with musculoskeletal diseases can be varied and complex. Conventional medicine can treat or modify pain due to musculoskeletal diseases; however, these may be associated with some side effects and at times may not be able to relieve pain completely. These treatment modalities also have ceiling effects like doses of analgesics, the number of nerve blocks, etc. Complementary and Alternative Medicine (CAM) provides a supplementary, unconventional modality to alleviate discomfort and disability associated with these mostly chronic conditions to manage activities of daily living. These modalities have been variedly combined with conventional management for symptom control and thus improve day-to-day activities. We assess the role of commonly used CAM modalities in the management of pain arising from Musculoskeletal diseases.

STW1 and Its Versatile Pharmacological and Clinical Effects in Rheumatic Disorders: A Comprehensive Report

Aim

To review the published and unpublished experimental and clinical studies about the efficacy and tolerability of STW1 and to compare the results to the efficacy and tolerability of investigated NSAIDs in parallel. Content. STW1 (Phytodolor®) contains a fixed combination of extracts from aspen leaves and bark (Populus tremula), common ash bark (Fraxinus excelsior), and goldenrod herb (Solidago virgaurea). It belongs to the group of anti-inflammatory and antirheumatic drugs, and it is authorized for the treatment of painful disorders of degenerative and inflammatory rheumatic diseases. The individual components have complementary effects. Its multifocal mode of action includes antiphlogistic, analgesic, antiexudative, antioxidative, antipyretic, and antiproliferative properties. The effects of both STW1 and its components have been verified in comprehensive pharmacological investigations. Open and randomized, placebo- and verum-controlled, and single-blind (sb) or double-blind (db) clinical trials, performed in different subtypes of rheumatic diseases confirm the pharmacological evidence. Its efficacy is comparable to a range of standard nonsteroidal anti-inflammatory drugs (NSAIDs) studied in parallel, but it has a superior safety profile.

Conclusion

STW1 is a reasonable alternative to NSAIDs with comparable efficacy and a superior safety profile. It is also suitable to reduce the intake of NSAIDs.

Methodological and reporting quality evaluation of meta-analyses on the Chinese herbal preparation Zheng Qing Feng Tong Ning for the treatment of rheumatoid arthritis

BACKGROUND

Zheng Qing Feng Tong Ning (ZQFTN) is a sinomenine (SIN) preparation that has been used in clinical practice. Our study aimed to assess the methodological and reporting quality of meta-analyses on the Chinese herbal formula ZQFTN for the treatment of rheumatoid arthritis (RA).

METHODS

Systematic searches were carried out with the 5 following electronic databases from inception to July 2019: China National Knowledge Infrastructure (CNKI), Wanfang, VIP database for Chinese technical periodicals (VIP), Cochrane Library and PubMed. The quality of the methodology and reporting was measured with the assessment of multiple systematic reviews 2 (AMSTAR 2) scale, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

RESULTS

Eight studies were identified. Among the 16 items of the AMSTAR 2 scale, four items were optimally reported ("Y" =100% of the items), and another four items were poorly reported ("Y" =0% of the items). Only 2 studies received a good overall score ("Y" ≥50% of the items). Regarding the PRISMA statement, the scores of 5 studies were lower than the average score (17.69), indicating that the quality of the reports was very low. In terms of the GRADE, none of the 61 results were of high quality (0.0%). Fifteen results were of medium quality (25%), 34 were of low quality (55%), and 12 were of very low quality (20%). Among the five downgrading factors, deviation risk (n = 61, 100%) was the most common downgrading factor, followed by inconsistency (n = 30, 50%), publication bias (n = 17, 28%), inaccuracy (n = 11, 18%) and indirectness (n = 0, 0%).

CONCLUSIONS

The methodological and reporting quality of the meta-analyses and systematic reviews in the included studies are less than optimal, and researchers should undergo additional training and follow the AMSTAR 2 scale, PRISMA statement and GRADE to design high-quality studies in the future.

Unraveling Natural Products' Role in Osteoarthritis Management-An Overview

The natural process of aging gradually causes changes in living organisms, leading to the deterioration of organs, tissues, and cells. In the case of osteoarthritis (OA), the degradation of cartilage is a result of both mechanical stress and biochemical factors. Natural products have already been evaluated for their potential role in the prevention and treatment of OA, providing a safe and effective adjunctive therapeutic approach. This review aimed to assess the therapeutic potential of natural products and their derivatives in osteoarthritis via a systematic search of literature after 2008, including in vitro, in vivo, ex vivo, and animal models, along with clinical trials and meta-analysis. Overall, 170 papers were obtained and screened. Here, we presented findings referring to the preventative and therapeutic potential of 17 natural products and 14 naturally occurring compounds, underlining, when available, the mechanisms implicated. The nature of OA calls to initially focus on the management of symptoms, and, in that context, several naturally occurring compounds have been utilized. Underlying a global need for more sustainable natural sources for treatment, the evidence supporting their chondroprotective potential is still building up. However, arriving at that kind of solution requires more clinical research, targeting the implications of long-term treatment, adverse effects, and epigenetic implications.

Harpagoside suppresses IL-6 expression in primary human osteoarthritis chondrocytes

There is growing evidence in support of the involvement of inflammatory response in the pathogenesis of osteoarthritis (OA). Harpagoside, one of the bioactive components of Harpagophytum procumbens (Hp), has been shown to possess anti-inflammatory properties. Here we used an in vitro model of inflammation in OA to investigate the potential of harpagoside to suppress the production of inflammatory cytokines/chemokines such as IL-6 and matrix degrading proteases. We further investigated the likely targets of harpagoside in primary human OA chondrocytes. OA chondrocytes were pre-treated with harpagoside before stimulation with IL-1β. mRNA expression profile of 92 cytokines/chemokines was determined using TaqMan Human Chemokine PCR Array. Expression levels of selected mRNAs were confirmed using TaqMan assays. Protein levels of IL-6 and MMP-13 were assayed by ELISA and immunoblotting. Total protein levels and phosphorylation of signaling proteins were determined by immunoblotting. Cellular localization of IL-6 and c-Fos was performed by immunofluorescence and confocal microscopy. DNA binding activity of c-FOS/AP-1 was determined by ELISA. Harpagoside significantly altered the global chemokine expression profile in IL-1β-stimulated OA chondrocytes. Expression of IL-6 was highly induced by IL-1β, which was significantly inhibited by pre-treatment of OA chondrocytes with harpagoside. Harpagoside did not inhibit the IL-1β-induced activation of NF-κB and C/EBPβ transcription factors but suppressed the IL-1β-triggered induction, phosphorylation, and DNA binding activity of c-FOS, one of the main components of AP-1 transcription factors. Further, harpagoside significantly inhibited the expression of MMP-13 in OA chondrocytes under pathological conditions. siRNA-mediated knockdown of IL-6 resulted in suppressed expression and secretion of MMP-13 directly linking the role of IL-6 with MMP-13 expression. Taken together, the present study suggests that harpagoside exerts a significant anti-inflammatory effect by inhibiting the inflammatory stimuli mediated by suppressing c-FOS/AP-1 activity in OA chondrocytes under pathological conditions. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:311-320, 2017.

Systemic Review and Meta-Analysis of the Clinical Efficacy and Adverse Effects of Zhengqing Fengtongning Combined with Methotrexate in Rheumatoid Arthritis

Chinese medicines are gaining wider acceptance. They have been used for treating rheumatoid arthritis (RA) for thousands of years, and the need to investigate the interaction between Chinese medicines and western medicines is widely recognized. In this study, a large number of RCTs and CCTs were analyzed to systematically assess the effects and adverse events of Zhengqing Fengtongning (ZQFTN) for RA. Eleven studies that contained 956 participants (508 in the treatment group; 448 in the control group) were included. The results showed that although ZQFTN combined with methotrexate MTX could not decrease the swollen joint count and tender joint count of RA patients better than MTX alone, the combination therapy might relieve the duration of morning stiffness (SMD: −16.06; 95% CI: −28.77 to −3.34), reduce laboratory indexes (RF: SMD: −10.84; 95% CI: −19.39 to −2.29; ESR: SMD: −7.26; 95% CI: −11.54 to −2.99; CRP: SMD: −3.66; 95% CI: −5.94 to −1.38), and improve the overall effect (RR: 1.08; CI: 1.01 to 1.16) better than monotherapy. The combination therapy was significantly better in controlling adverse drug reactions (RR: 0.60; 95% CI: 0.46 to 0.79). Through this systematic review, we found that ZQFTN combined with MTX for the treatment of RA might have better clinical efficacy than MTX only and might be superior in terms of controlling adverse drug reactions.

The Effects of Topical Sesame (Sesamum indicum) Oil on Pain Severity and Amount of Received Non-Steroid Anti-Inflammatory Drugs in Patients With Upper or Lower Extremities Trauma

Background:

Most patients with trauma experience different levels of pain. Due to side effects as well as economic burden of drugs used for pain relief after trauma commonly, it is important to use low-cost methods independently or combined with drugs to alleviate pain.

Objectives:

Therefore, this study aimed to investigate the effects of topical sesame oil on pain severity and frequency of received NSAIDs of patients with trauma.

Patients and Methods:

This randomized clinical trial study was conducted on 150 patients with upper or lower extremities trauma in Dezful Ganjavian Hospital, Ahvaz, Iran, in 2014. Data was collected by a researcher-made questionnaire and Visual Analogue Scale (VAS). Patients were divided into two groups of control (n = 75) and intervention (n = 75) randomly. In the intervention group, patients applied topical sesame oil beside the routine cares, while in the control group patients just received routine cares. Severity of pain and frequency of received NSAIDs was assessed in the first, third, seventh and tenth days after the intervention in the both groups. Data was analyzed by SPSS19 software using descriptive and analytic (Chi-square and independent sample t-test) statistical methods.

Results:

Based on student sample t-test, there was a significant difference between intervention and control groups regarding the pain severity in the first (P = 0.06), third (P = 0.001), seventh (P = 0.001) and tenth (P = 0.001) days after the intervention. Besides, the frequency of received NSAIDs in the intervention group and the control group showed significant difference in four days after the intervention (for four days P = 0.001).

Conclusions:

Topical application of sesame oil could reduce pain severity and frequency of received NSAIDs in patients with upper or lower extremities trauma. Therefore, it is recommended to use this oil in complementary medicine for pain relief due to low cost, easy usage and lack of adverse effects.

An Evidence-Based Systematic Review of Black cohosh (Cimicifuga racemosa, Actaea racemosa) by the Natural Standard Research Collaboration

An evidence-based systematic review of black cohosh (Cimicifuga racemosa, Actaea racemosa) by the Natural Standard Research Collaboration consolidates the safety and efficacy data available in the scientific literature using a validated, reproducible grading rationale. This article includes written and statistical analysis of clinical trials, plus a compilation of expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing.

Traditional medicines in Africa: an appraisal of ten potent african medicinal plants

The use of medicinal plants as a fundamental component of the African traditional healthcare system is perhaps the oldest and the most assorted of all therapeutic systems. In many parts of rural Africa, traditional healers prescribing medicinal plants are the most easily accessible and affordable health resource available to the local community and at times the only therapy that subsists. Nonetheless, there is still a paucity of updated comprehensive compilation of promising medicinal plants from the African continent. The major focus of the present review is to provide an updated overview of 10 promising medicinal plants from the African biodiversity which have short- as well as long-term potential to be developed as future phytopharmaceuticals to treat and/or manage panoply of infectious and chronic conditions. In this endeavour, key scientific databases have been probed to investigate trends in the rapidly increasing number of scientific publications on African traditional medicinal plants. Within the framework of enhancing the significance of traditional African medicinal plants, aspects such as traditional use, phytochemical profile, in vitro, in vivo, and clinical studies and also future challenges pertaining to the use of these plants have been explored.

Evidence for the efficacy of complementary and alternative medicines in the management of osteoarthritis: a systematic review

Objectives. To critically evaluate the evidence regarding complementary and alternative medicine (CAM) taken orally or applied topically (excluding glucosamine and chondroitin) in the treatment of OA. Methods. Randomized clinical trials of OA using CAMs, in comparison with other treatments or placebo, published in English up to January 2009, were eligible for inclusion. They were identified using systematic searches of bibliographic databases and manual searching of reference lists. Information was extracted on outcomes, and statistical significance, in comparison with alternative treatment of placebo, and side effects were reported. The methodological quality of the primary studies was determined. Results. The present review found consistent evidence that capsaicin gel and S-adenosyl methionine were effective in the management of OA. There was also some consistency to the evidence that Indian Frankincense, methylsulphonylmethane and rose hip may be effective. For other substances with promising evidence, the evidence base was either insufficiently large or the evidence base was inconsistent. Most of the CAM compounds studied were free of major adverse effects. Conclusion. The major limitation in reviewing the evidence is the paucity of randomized controlled trials in the area: widening the evidence base, particularly for those compounds for which there is promising evidence, should be a priority for both researchers and funders.

Complementary treatments in rheumatic diseases

Which complementary therapies are effective for reducing pain in which rheumatic conditions? This is the question this article addresses, with particular emphasis on treatments that are, according to the totality of the available trial data, likely to be effective, and with a focus on six conditions relevant to rheumatologists: back pain, fibromyalgia, myofascial pain, neck pain, osteoarthritis, and rheumatoid arthritis.

Effect of the major glycosides of Harpagophytum procumbens (Devil's Claw) on epidermal cyclooxygenase-2 (COX-2) in vitro

Harpagophytum procumbens, commonly known as Devil's Claw, is indigenous to southern Africa, and extracts of the tubers have been used for centuries in the treatment of a variety of inflammatory disorders. Its major active components, harpagoside (1), harpagide (2), 8-coumaroylharpagide (3), and verbascoside (4), are believed to interact either synergistically or antagonistically in modulating the enzymes responsible for inducing inflammation, although this has not been probed hitherto. In the current work, the ability of these compounds to inhibit the expression of COX-2 following administration to freshly excised porcine skin has been investigated. An ethanol-soluble extract of H. procumbens tubers and two of the pure compounds tested showed promising activity in Western blotting and immunocytochemical assays, with harpagoside (1) and 8-coumaroylharpagide (3) exhibiting greater reductions in COX-2 expression than verbascoside (4). Harpagide (2) caused a significant increase in the levels of COX-2 expression after 6 h of topical application. The data suggest that the efficacy of H. procumbens is dependent upon the ratios of compounds 1-4 present, which is inconsistent with some current official monograph specifications based solely on harpagoside (1) content.

Devil's Claw (Harpagophytum procumbens) as a treatment for osteoarthritis: a review of efficacy and safety

BACKGROUND

Osteoarthritis (OA) is a highly prevalent musculoskeletal disorder. Conventional treatment (i.e., the use of nonsteroidal anti-inflammatory drugs-NSAIDs) is associated with well-documented adverse effects. Devil's Claw (Harpagophytum procumbens) a traditional South African herbal remedy used for rheumatic conditions, may be a safer treatment option. To date, 14 clinical trials have assessed its efficacy/ effectiveness in OA.

AIM

To address the two main questions of importance to clinicians: (1) Does Devil's Claw work for the treatment of OA, and (2) Is it safe?

METHODS

A review of the literature on Devil's Claw and OA from 1966 to 2006 was performed using multiple search databases, monographs, and citation tracking. Relevant trials in all languages were identified and included. Both internal validity (i.e., adequacy of the dosage and period of treatment for this condition, reporting of randomization, rates of dropout, blinding, and statistical analysis) and external validity (i.e., inclusion/ exclusion criteria, baseline characteristics of the study populations, trial setting, and the appropriateness of the outcome measures of the trials) were assessed.

RESULTS

Fourteen studies were identified: eight observational studies; 2 comparator trials (1 open, the other randomized to assess clinical effectiveness); and 4 double-blinded, placebo-controlled, randomized controlled trials to assess efficacy. Many of the published trials lacked certain important methodological quality criteria. However, the data from the higher quality studies suggest that Devil's Claw appeared effective in the reduction of the main clinical symptom of pain. The assessment of safety is limited by the small populations generally evaluated in the clinical studies. From the current data, Devil's Claw appears to be associated with minor risk (relative to NSAIDs), but further long-term assessment is required.

CONCLUSIONS

The methodological quality of the existing clinical trials is generally poor, and although they provide some support, there are a considerable number of methodologic caveats that make further clinical investigations warranted. The clinical evidence to date cannot provide a definitive answer to the two questions posed: (1) Does it work? And (2) is it safe? A definitive high-quality trial that addresses the necessary methodologic improvements noted is needed to answer these important clinical questions.

Racial/Ethnic Differences in the Use of Complementary and Alternative Medicine in Patients With Arthritis

OBJECTIVE

To examine use of complementary and alternative medicine (CAM) by individuals with osteoarthritis (OA) from 4 ethnic groups, differences in CAM use among groups, and correlates of CAM use.

METHODS

Data were obtained from individuals from 4 ethnic groups (African, Asian, and Hispanic Americans, and Caucasians) participating in trials assessing celecoxib efficacy. A questionnaire assessing CAMs specifically used to help arthritis was administered at screening. Use of 42 specific therapies within 7 categories-alternative medical systems, mind-body interventions, manipulation and body-based methods, energy therapies, and 3 types of biologically based therapies--was queried.

RESULTS

More than 80% of subjects reported that they used some CAM for arthritis in the past month. In contrast, 50% reported the use of prescription medicines, and 52% reported the use of over-the-counter medicines. Dietary practices were the most common type of CAM (71.5%), followed by mind-body interventions (42.4%), topical agents (38.1%), use of supplements or herbs (32.9%), and manipulation and body-based methods (21.4%). African Americans were more likely to report any CAM use than other groups (89.1% versus 83.1% [Asian], 81.1% [Hispanic], 77.7% [Caucasian]). African and Asian Americans more commonly reported the use of mind-body interventions in general, and prayer in particular. African Americans were also most likely to report the use of topical agents. Asian Americans were most likely to report use of alternative medical systems, manipulation methods, and supplements. Caucasians were least likely to report use of dietary practices.

CONCLUSION

Individuals with OA commonly use CAM. Use of these therapies varies by racial/ethnic group. Some CAMs may be effective for symptom relief, while others may interact with prescription medications, suggesting that routine queries by physicians concerning CAM use would be beneficial.

Evidence of effectiveness of herbal antiinflammatory drugs in the treatment of painful osteoarthritis and chronic low back pain

Treatment with herbal medicines is very popular in Europe. In order to get information on the evidence of effectiveness of oral herbal medicines in the treatment of pain in the joints or lower back, OVID(MEDLINE), PUBMED and COCHRANE COLLABORATION LIBRARY were searched back to 1985 for systematic reviews. The level of evidence of effectiveness was defined as strong - at least two confirmatory studies demonstrating a clinical relevant effect, moderate - one confirmatory study with a clinical relevant effect and/or multiple exploratory studies of good quality; otherwise the evidence was insufficient or conflicting in the case of inconsistent findings. Fifteen systematic reviews were identified. The evidence of effectiveness was strong for a proprietary unsaponifiable avocado soybean fraction and Harpagophytum preparations containing > 50 mg harpagoside in the daily dosage, moderate for ginger and a proprietary rose hip and seed powder, insufficient for Boswellia serrata gum resin and other herbal preparations and inconsistent for a proprietary willow bark extract. Further rigorous studies are required to confirm the usefulness of herbal medicines in the treatment of osteoarthritic complaints and chronic low back pain in order to enable acceptance of the herbal medicines into the treatment guidelines.

Food for thought

Do certain kinds of food contain pharmacologically active substances in concentrations that are high enough to have druglike effects when consumed? Are biologically active compounds in food indicative of therapeutic value? Is traditional drug development suitable for testing the merits of food? Is it ethical to test food as a drug on patients? Will dietary disease management remain a pipedream? Is it a fact or fantasy that the Mediterranean diet is beneficial to health? Is a vegetarian diet an elimination therapy, or one of supplementation? What can be learned from animals? Are humans losing the capability of listening to their bodies? In this review, we will address these questions--providing food for thought.

Regulation of vascular responses to inflammation: inducible matrix metalloproteinase-3 expression in human microvascular endothelial cells is sensitive to antiinflammatory Boswellia

Endothelial cells are critical elements in the pathophysiology of inflammation. Tumor necrosis factor (TNF) alpha potently induces inflammatory responses in endothelial cells. Recently we have examined the genetic basis of the antiinflammatory effects of Boswellia extract (BE) in a system of TNFalpha-induced gene expression in human microvascular endothelial cells (HMECs). Of the 522 genes induced by TNFalpha in HMECs, 113 genes were sensitive to BE. BE prevented the TNFalpha-induced expression of matrix metalloproteinases (MMPs). In the current work, we sought to test the effects of BE on TNFalpha-inducible MMP expression in HMECs. Acetyl-11-ketobeta- boswellic acid (AKBA) is known to be an active principle in BE. To evaluate the significance of AKBA in the antiinflammatory properties of BE, effects of BE containing either 3% (BE3%) or 30% (BE30%, 5- Loxin) were compared. Pretreatment of HMECs for 2 days with BE potently prevented TNFalpha-induced expression and activity of MMP-3, MMP-10, and MMP-12. In vivo, BE protected against experimental arthritis. In all experiments, both in vitro and in vivo, BE30% was more effective than BE3%. In sum, this work lends support to our previous report that BE has potent antiinflammatory properties both in vitro as well as in vivo.

Use of Complementary and Alternative Medicine in Pediatric Pain Management Service: A Survey: Table 1

OBJECTIVE

To survey the use of complementary and alternative medical therapies by pediatric pain management services affiliated with major universities.

DESIGN

A telephone survey was conducted of pediatric anesthesia training programs accredited by the Accreditation Council for Graduate Medical Education in the United States. The survey instrument included questions on the provision of complementary and alternative medical therapies in their pediatric pain programs.

RESULTS

Forty-three pediatric anesthesia fellowship programs (100%) responded to the survey. Thirty-eight institutions (86%) offered one or more complementary and alternative medical therapies for their patients. Those therapies included biofeedback (65%), guided imagery (49%), relaxation therapy (33%), massage (35%), hypnosis (44%), acupuncture (33%), art therapy (21%), and meditation (21%).

CONCLUSIONS

This report documents trends in complementary and alternative medical therapies usage in the tertiary pediatric pain management service. There is a high prevalence in the integration of complementary and alternative medical therapies in pediatric pain management programs. Additional clinical research in the safety and efficacy in complementary and alternative medical therapies for pediatric pain management is urgently needed.

Essais cliniques des médicaments à base de plantes : revue bibliographique

BACKGROUND

The importance of traditional medicine, one of the fundamentals of the cultural heritage of African, Asian and South American peoples, is evident in that such medicine is practised by more than 80% of these populations.

METHODS

To analyse the methodology of clinical trials using medicinal plants, we reviewed articles published on this topic between 1980 and 2000.

RESULTS

Forty-eight clinical trials were identified. Most were carried out in developed countries. Standard methodological principles were applied in almost all the trials: randomisation (85.4%), comparison (87.5%) versus placebo (95.2%), and blinded design (81.3%). The duration of the studies was short. Sample sizes were generally small, ranging from 30 to 99 subjects; statistical tests were used in 90% of the trials. Adverse effects were infrequently collected.

CONCLUSION

Most clinical trials included in this survey were conducted in accordance with WHO guidelines. Respect for methodological principles and the implementation of a legislative framework are important in obtaining credibility and international recognition of the traditional pharmacopoeia.

Human genome screen to identify the genetic basis of the anti-inflammatory effects of Boswellia in microvascular endothelial cells

Inflammatory disorders represent a substantial health problem. Medicinal plants belonging to the Burseraceae family, including Boswellia, are especially known for their anti-inflammatory properties. The gum resin of Boswellia serrata contains boswellic acids, which inhibit leukotriene biosynthesis. A series of chronic inflammatory diseases are perpetuated by leukotrienes. Although Boswellia extract has proven to be anti-inflammatory in clinical trials, the underlying mechanisms remain to be characterized. TNF alpha represents one of the most widely recognized mediators of inflammation. One mechanism by which TNFalpha causes inflammation is by potently inducing the expression of adhesion molecules such as VCAM-1. We sought to test the genetic basis of the antiinflammatory effects of BE (standardized Boswellia extract, 5-Loxin) in a system of TNF alpha-induced gene expression in human microvascular endothelial cells. We conducted the first whole genome screen for TNF alpha- inducible genes in human microvascular cells (HMEC). Acutely, TNF alpha induced 522 genes and downregulated 141 genes in nine out of nine pairwise comparisons. Of the 522 genes induced by TNF alpha in HMEC, 113 genes were clearly sensitive to BE treatment. Such genes directly related to inflammation, cell adhesion, and proteolysis. The robust BE-sensitive candidate genes were then subjected to further processing for the identification of BE-sensitive signaling pathways. The use of resources such as GenMAPP, KEGG, and gene ontology led to the recognition of the primary BE-sensitive TNF alpha-inducible pathways. BE prevented the TNF alpha-induced expression of matrix metalloproteinases. BE also prevented the inducible expression of mediators of apoptosis. Most strikingly, however, TNF alpha-inducible expression of VCAM-1 and ICAM-1 were observed to be sensitive to BE. Realtime PCR studies showed that while TNF alpha potently induced VCAM-1 gene expression, BE completely prevented it. This result confirmed our microarray findings and built a compelling case for the anti-inflammatory property of BE. In an in vivo model of carrageenan-induced rat paw inflammation, we observed a significant antiinflammatory property of BE consistent with our in vitro findings. These findings warrant further research aimed at identifying the signaling mechanisms by which BE exerts its anti-inflammatory effects.

Complementary and Alternative Pain Therapy in the Emergency Department

One primary reason patients go to emergency departments is for pain relief. Understanding the physiologic dynamics of pain, pharmacologic methods for treatment of pain, as well CAM therapies used in treatment of pain is important to all providers in emergency care. Asking patients about self-care and treatments used outside of the emergency department is an important part of the patient history. Complementary and alternative therapies are very popular for painful conditions despite the lack of strong research supporting some of their use. Even though evidenced-based studies that are double blinded and show a high degree of interrater observer reliability do not exist, patients will likely continue to seek out CAM therapies as a means of self-treatment and a way to maintain additional life control. Regardless of absolute validity of a therapy for some patients, it is the bottom line: "it seems to help my pain." Pain management distills down to a very simple endpoint, patient relief, and comfort. Sham or science, if the patient feels better, feels comforted, feels less stressed, and more functional in life and their practices pose no health risk, then supporting their CAM therapy creates a true wholistic partnership in their health care.CAM should be relatively inexpensive and extremely safe. Such is not always the case, as some patients have discovered with the use of botanicals. It becomes an imperative that all providers be aware of CAM therapies and informed about potential interactions and side effects when helping patients manage pain and explore adding CAM strategies for pain relief. The use of regulated breathing, meditation, guided imagery, or a massage for a pain sufferer are simple but potentially beneficial inexpensive aids to care that can be easily employed in the emergency department. Some CAM therapies covered here, while not easily practiced in the emergency department, exist as possibilities for exploration of patients after they leave, and may offer an improved sense of well-being and empowerment in the face of suffering and despair. The foundations of good nutrition, exercise, stress reduction, and reengagement in life can contribute much to restoring the quality of life to a pain patient. Adding nondrug therapies of physical therapy, cognitive-behavioral therapy, TENS, hypnosis, biofeedback, psychoanalysis, and others can complete the conventional picture. Adding in simple mind/body therapies, touch therapies, acupuncture, or others may be appropriate in select cases, and depending on the circumstances, may effect and enhance a conventional pain management program. Armed with an understanding of pain dynamics and treatments, practitioners can better meet patient needs, avoid serious side effects, and improve care when addressing pain management in the emergency department.

Complementary and Alternative Approaches to the Treatment of Persistent Musculoskeletal Pain

OBJECTIVE

To review common complementary and alternative treatment modalities for the treatment of persistent musculoskeletal pain in older adults.

METHODS

A critical review of the literature on acupuncture and related modalities, herbal therapies, homeopathy, and spinal manipulation was carried out. Review included 678 cases within 21 randomized trials and 2 systematic reviews of herbal therapies: 798 cases within 2 systematic reviews of homeopathy; 1,059 cases within 1 systematic review of spinal manipulation for low back pain, and 419 cases within 4 randomized controlled trials for neck pain. The review of acupuncture and related modalities was based upon a paucity of well-controlled studies combined with our clinical experience.

RESULTS

Insufficient experimental evidence exists to recommend the use of traditional Chinese acupuncture over other modalities for older adults with persistent musculoskeletal pain. Promising preliminary evidence exists to support the use of percutaneous electrical nerve stimulation for persistent low back pain. While some herbals appear to have modest analgesic benefits, insufficient evidence exists to definitively recommend their use. Drug-herb interactions must also be considered. Some evidence exists to support the superiority of homeopathic remedies over placebo for treating osteoarthritis and rheumatoid arthritis. The benefits of spinal manipulation for persistent low back and neck pain have not been convincingly shown to outweigh its risks.

DISCUSSION

While the use of complementary and alternative modalities for the treatment of persistent musculoskeletal pain continues to increase, rigorous clinical trials examining their efficacy are needed before definitive recommendations regarding the application of these modalities can be made.

Selected CAM Therapies for Arthritis-Related Pain: The Evidence From Systematic Reviews

OBJECTIVES

The purpose is to examine what is known about the efficacy of selected complementary and alternative medicine (CAM) therapies for pain from arthritis and related conditions based on systematic reviews and meta-analyses.

METHODS

Results specifically related to pain were retrieved from review articles of acupuncture, homeopathy, herbal remedies, and selected nutritional supplements.

RESULTS

Evidence exists to support the efficacy of reducing pain from osteoarthritis (OA) for acupuncture; devil's claw, avocado/soybean unsaponifiables, Phytodolor and capsaicin; and chondroitin, glucosamine, and SAMe. Strong support exists for gamma linolenic acid (GLA) for pain of rheumatoid arthritis (RA).

CONCLUSIONS

Despite support for some of the most popular CAM therapies for pain from arthritis-related conditions, additional high quality research is needed for other therapies, especially for herbals and homeopathy.

Treating inflammation: some (needless) difficulties for gaining acceptance of effective natural products and traditional medicines

The quality of so-called 'natural medicines' is extraordinarily variable. Lack of resolute pharmacological assays contributes to this hiatus. More stringent evaluation of anti-inflammatory and anti-pyretic activities in rats can help resolve some of the uncertainties surrounding (a) preparations of some herbal products including so-called 'nature's aspirin' (e.g. willowbark, ginger), cat's claw, celery seed, etc., and (b) some animal lipids (e.g. Lyprinol(R) (NZ Mussel), emu and fish oils). These animal products can be a remarkable resource for supplementing conventional/allopathic therapy for inflammatory disease, e.g. providing lipoxygenase inhibitors. Beyond the verifiable science, the healing professions and the general public still need to examine more carefully criteria for QUALITY(S) in any alternative medicine-to ensure the good (= both reputations and products) are not destroyed by the bad-in essence counteracting Gresham's Law which states: the bad tends to displace the good.

Systematic reviews of complementary therapies - an annotated bibliography. Part 2: herbal medicine

BACKGROUND

Complementary therapies are widespread but controversial. We aim to provide a comprehensive collection and a summary of systematic reviews of clinical trials in three major complementary therapies (acupuncture, herbal medicine, homeopathy). This article is dealing with herbal medicine. Potentially relevant reviews were searched through the register of the Cochrane Complementary Medicine Field, the Cochrane Library, Medline, and bibliographies of articles and books. To be included articles had to review prospective clinical trials of herbal medicines; had to describe review methods explicitly; had to be published; and had to focus on treatment effects. Information on conditions, interventions, methods, results and conclusions was extracted using a pre-tested form and summarized descriptively.

RESULTS

From a total of 79 potentially relevant reviews pre-selected in the screening process 58 met the inclusion criteria. Thirty of the reports reviewed ginkgo (for dementia, intermittent claudication, tinnitus, and macular degeneration), hypericum (for depression) or garlic preparations (for cardiovascular risk factors and lower limb atherosclerosis). The quality of primary studies was criticized in the majority of the reviews. Most reviews judged the available evidence as promising but definitive conclusions were rarely possible.

CONCLUSIONS

Systematic reviews are available on a broad range of herbal preparations prescribed for defined conditions. There is very little evidence on the effectiveness of herbalism as practised by specialist herbalists who combine herbs and use unconventional diagnosis.

Complementary therapies in palliative cancer care

BACKGROUND

Complementary medicine has become an important aspect of palliative cancer care. This overview is primarily aimed at providing guidance to clinicians regarding some commonly used complementary therapies.

METHODS

Several complementary therapies were identified as particularly relevant to palliative cancer care. Exemplary studies and, where available, systematic reviews are discussed.

RESULTS

Promising results exist for some treatments, e.g. acupuncture, enzyme therapy, homeopathy, hypnotherapy, and relaxation techniques. Unfortunately, the author finds that the evidence is not compelling for any of these therapies.

CONCLUSION

These results point to some potential for complementary medicine in palliative care. They also demonstrate an urgent need for more rigorous research into the value (or otherwise) of such treatments in palliative and supportive cancer care.

Complementary and alternative therapies for rheumatic disease

Patients with rheumatic disease are turning to complementary and alternative therapies in growing numbers. Many of these therapies have a long history of apparent safety and efficacy but have not been adequately tested in controlled trials. To aid physicians in guiding patients' decisions, the most frequently used products and practices are reviewed.

Complementary and alternative therapies for fibromyalgia

Fibromyalgia (FM) is a syndrome of chronic widespread musculoskeletal pain that is accompanied by sleep disturbance and fatigue. Clinical treatment usually includes lifestyle modifications and pharmacologic interventions meant to relieve pain, improve sleep quality, and treat mood disorders. These therapies are often ineffective or have been shown in clinical studies to have only short-term effectiveness. Pharmacologic treatments have considerable side effects. Patients may have difficulty complying with exercise-based treatments. Thus, patients seek alternative therapeutic approaches and physicians are routinely asked for advice about these treatments. This article reviews nontraditional treatment alternatives, from use of nutritional and herbal supplements to acupuncture and mind-body therapy. Little is known about efficacy and tolerance of complementary and alternative therapies in FM and other chronic musculoskeletal pain syndromes. Most studies on these treatments have been performed for osteoarthritis, rheumatoid arthritis, or focal musculoskeletal conditions. Clinical trials are scarce; the quality of these trials is often criticized because of small study population size, lack of appropriate control interventions, poor compliance, or short duration of follow-up. However, because of widespread and growing use of alternative medicine, especially by persons with chronic illnesses, it is essential to review efficacy and adverse effects of complementary and alternative therapies.

Inhibition of TNF-alpha synthesis in LPS-stimulated primary human monocytes by Harpagophytum extract SteiHap 69

Harpagophytum procumbens (Devil's Claw) is often used in the supportive treatment of inflammatory and degenerative diseases of the skeletal system. Here we studied the anti-inflammatory properties of the Harpagophytum extract SteiHap 69 (Steiner Harpagophytum procumbens extract 69) on primary human monocytes, a useful model of peripheral inflammation. After eliminating lipopolysaccharides of bacterial origin, SteiHap 69 prevented the LPS-induced synthesis of tumour necrosis factor alpha (TNFalpha) in stimulated primary human monocytes in a dose-dependent manner. Harpagide and harpagoside had no effect on LPS-induced TNFalpha-release. Our data provides evidence that the Harpagophytum extract SteiHap 69 has anti-inflammatory properties. Further studies are required in order to elucidate the molecular mechanism of Devil's claw anti-inflammatory effects.

Complementary and alternative medicine in rheumatology

Complementary and alternative medicine (CAM) has become an important subject for rheumatologists. This article is an attempt to provide an introduction to this subject. It will provide definitions of, and define the prevalence of, CAM. The emphasis of the article is on evaluating the efficacy of CAM treatment modalities. This is achieved by referring to systematic reviews of clinical trials of acupuncture for low back pain, osteo-arthritis, fibromyalgia, inflammatory rheumatoid disease and neck pain. Further areas addressed in this way are herbal remedies, fish oil and glucosamine. Moreover, massage therapy and spinal manipulation for back pain are discussed. The final sections of this review deal with the safety and cost of CAM. It is concluded that, in view of the popularity of CAM with rheumatological patients, rigorous research into CAM is the best way forward.

Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study

PURPOSE

Herbal medicines are widely used for the treatment of pain, although there is not much information on their effectiveness. This study was designed to evaluate the effectiveness of willow (Salix) bark extract, which is widely used in Europe, for the treatment of low back pain.

SUBJECTS AND METHODS

We enrolled 210 patients with an exacerbation of chronic low back pain who reported current pain of 5 or more (out of 10) on a visual analog scale. They were randomly assigned to receive an oral willow bark extract with either 120 mg (low dose) or 240 mg (high dose) of salicin, or placebo, with tramadol as the sole rescue medication, in a 4-week blinded trial. The principal outcome measure was the proportion of patients who were pain-free without tramadol for at least 5 days during the final week of the study.

RESULTS

The treatment and placebo groups were similar at baseline in 114 of 120 clinical features. A total of 191 patients completed the study. The numbers of pain-free patients in the last week of treatment were 27 (39%) of 65 in the group receiving high-dose extract, 15 (21%) of 67 in the group receiving low-dose extract, and 4 (6%) of 59 in the placebo group (P <0.001). The response in the high-dose group was evident after only 1 week of treatment. Significantly more patients in the placebo group required tramadol (P <0.001) during each week of the study. One patient suffered a severe allergic reaction, perhaps to the extract.

CONCLUSION

Willow bark extract may be a useful and safe treatment for low back pain.