Boswellia–Curcumin Preparation for Treating Knee Osteoarthritis: A Clinical Evaluation

Medical treatment of osteoarthritis: botanical pharmacologic aspect

Osteoarthritis (OA) is the most common form of arthritis, and its prevalence is expected to further increase as our society ages. Despite many approaches to cure OA, no drugs are currently proven to modulate the progression of OA. Nowadays, new OA treatment options are holistically developed and one of the approaches of treatment option is botanical drugs. Some botanical drugs for OA have shown both therapeutic effect comparable to refined drugs in small studies and fewer side effects. Hence, there are various health functional foods which are known to relieve symptoms of OA. However, since there are many botanical products, clinicians are not familiar to the efficacy of each botanical product, making it challenging to use them appropriately in clinical practice. Here, we summarize the botanical products available for treating OA, including prescription botanical drugs and health functional foods available in Korea. Further studies and the purification of effective molecules from botanical products will be necessary in future.

Anti-cancer effect of nano-encapsulated boswellic acids, curcumin and naringenin against HepG-2 cell line

BACKGROUND

liver cancer is one of the most common cancers in the world. So far, there is no gold standard treatment for hepatocellular carcinoma. We conducted this in vitro study to assess the effect of three natural products: Boswellic acids, curcumin and naringin versus corresponding nanoparticles (NPs) on Hep G2 cells proliferation.

METHODS

Boswellic acid, curcumin, naringin-loaded NPs were prepared using nanoprecipitation method. Human liver (HepG2) cell line was cultured in Dulbecco's modified Eagle's medium (DMEM). The cell growth inhibition and cytotoxicity were evaluated by MTT assay.

RESULTS

Boswellic acid, curcumin, naringin were able to inhibit HepG2 cells proliferation. IC50 at 24 h, 48 h showed significant lower values in NPs versus Free herbs. IC50 values of free Boswellic acids and NPs at 24 h were (24.60 ± 1.89 and 7.78 ± 0.54, P < 0.001), at 48 h were (22.45 ± 1.13 and 5.58 ± 0.27, P < 0.001) respectively. IC50 values of free curcumin and NPs at 24 h were (5.89 ± 0.8 and 3.46 ± 0.23, P < 0.05), at 48 h were (5.57 ± 0.94 and 2.51 ± 0.11, P < 0.05), respectively. For free and naringenin NPs, IC50 values at 24 h were (14.57 ± 1.78 and 7.25 ± 0.17, P < 0.01), at 48 h were (11.37 ± 1.45 and 5.21 ± 0.18, P < 0.01) respectively.

CONCLUSION

Boswellic acid, curcumin, naringin and their nanoprecipitation prepared nanoparticles suppressed Hep G2 cells proliferation.

Efficacy and Safety of Curcumin and Curcuma longa Extract in the Treatment of Arthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trial

Background

Modern pharmacological research found that the chemical components of Curcuma longa L. are mainly curcumin and turmeric volatile oil. Several recent randomized controlled trials (RCT) have shown that curcumin improves symptoms and inflammation in patients with arthritis.

Methods

Pubmed, Cochran Library, CNKI, and other databases were searched to collect the randomized controlled trials (RCTs). Then, the risk of bias of RCTs were assessed and data of RCTs were extracted. Finally, RevMan 5.3 was utilized for meta-analysis.

Results

Twenty-nine (29) RCTs involving 2396 participants and 5 types of arthritis were included. The arthritis included Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA), Osteoarthritis (OA), Juvenile idiopathic arthritis (JIA) and gout/hyperuricemia. Curcumin and Curcuma longa Extract were administered in doses ranging from 120 mg to 1500 mg for a duration of 4-36 weeks. In general, Curcumin and Curcuma longa Extract showed safety in all studies and improved the severity of inflammation and pain levels in these arthritis patients. However, more RCTs are needed in the future to elucidate the effect of Curcumin and Curcuma longa Extract supplementation in patients with arthritis, including RA, OA, AS and JIA.

Conclusion

Curcumin and Curcuma longa Extract may improve symptoms and inflammation levels in people with arthritis. However, due to the low quality and small quantity of RCTs, the conclusions need to be interpreted carefully.

The efficacy and safety of Curcuma longa extract and curcumin supplements on osteoarthritis: a systematic review and meta-analysis

Objective: To assess the efficacy and safety of Curcuma longa extract and curcumin supplements on osteoarthritis (OA).

Methods: The databases such as Pubmed and Cochrane Library were searched to collect the article about Curcuma longa extract and curcumin in the treatment of OA. Then, randomized controlled trials (RCTs) were selected and their data were extracted. Finally, the RevMan5.3 was utilized for risk of bias assessment and meta-analysis, the STATA15.0 were utilized for publication bias assessment, and GRADE tool were used for the evidence quality assessment of primary outcomes.

Results: A total of 15 RCTs involving 1621 participants were included. (1) Compared with placebo, Curcuma longa extract and curcumin (C.) can decrease the visual analog scale (VAS) and The Western Ontario and McMaster Universities (WOMAC) score-pain, the WOMAC score-function and the WOMAC score-stiffness. In terms of adverse events, Curcuma longa extract and curcumin are comparable with those of placebo. (2) Compared with non-steroidal anti-inflammatory drugs (NSAIDs), Curcuma longa extract and curcumin have similar effects on joint pain, function and stiffness. The incidence of adverse events in Curcuma longa extract and curcumin was lower. (3) Compared with the NSAIDs group, C.+NSAIDs can also decrease the VAS and WOMAC score-pain, the WOMAC score-function and the WOMAC score-stiffness. In terms of adverse events, the addition of Curcuma longa extract and curcumin to NSAIDs did not increase adverse events.

Conclusion:Curcuma longa extract and curcumin may be a safer and effective supplement for OA patients. It is recommended to use Curcuma longa extract and curcumin supplement for OA patients for more than 12 weeks.

Formulation of Nanospanlastics as a Promising Approach for ‎Improving the Topical Delivery of a Natural Leukotriene Inhibitor (3-‎Acetyl-11-Keto-β-Boswellic Acid): Statistical Optimization, in vitro ‎Characterization, and ex vivo Permeation Study

Purpose

The current study aimed to discuss the potential of nanospanlastics as a surfactant-based vesicular system for improving the topical delivery of 3-acetyl-11-keto-β-boswellic acid (AKBA). AKBA is a potent anti-inflammatory drug, but it has poor oral bioavailability due to its poor aqueous solubility. Moreover, the topical delivery of AKBA is difficult due to its high lipophilicity. To overcome these drawbacks, AKBA was formulated as deformable elastic nanovesicles and nanospanlastics, for improving its topical delivery.

Materials and Methods

AKBA-loaded spanlastic nanovesicles (SNVs) were formulated by ethanol injection technique according to 2³ factorial design using Span 60 as a non-ionic surfactant and Tween 80 as edge activator (EA) to investigate the effect of different independent variables on entrapment efficiency (EE%), % drug released after 8 hr (Q_8h) and particle size (PS) using Design-Expert software. In vitro characterization, stability test and ex vivo permeation study of the optimized formula were performed.

Results

The choice of the optimized formula was based on the desirability criteria.‎ F7 was selected as the optimized formula because it has the highest desirability value of 0.648. F7 exhibited EE% of 90.04±0.58%, Q_8h of 96.87±2.67%, PS of 255.8±2.67 nm, and zeta potential of −49.56 mV. F7 appeared as spherical well-defined vesicles in both scanning electron microscope (SEM) and transmission electron microscope (TEM). The Fourier transform infrared spectroscopy (FTIR) and differential scanning calorimetry (DSC) studies investigated the absence of interaction between AKBA and ‎different excipients and good encapsulation of AKBA within SNVs. F7 retained both physical and chemical stability after storage for 3 months at 4–8 °C. Ex vivo permeation test exhibited significant enhancement of permeability of F7 across rat skin than the free drug.

Conclusion

Nanospanlastics could be a promising approach for improving the permeability and topical delivery of AKBA.

Effectiveness of Boswellia and Boswellia extract for osteoarthritis patients: a systematic review and meta-analysis

Background

Osteoarthritis (OA) is the commonest form of inflammatory joint disease. Unfortunately, to date, there is no appropriate treatment for OA. Boswellia serrata was considered as a potent anti-inflammatory, anti-arthritic and analgesic agent that may be a drug for OA.

Methods

In this meta-analysis, data from randomized controlled trials were obtained to assess the effects of Boswellia or its extract versus placebo or western medicine in patients with OA. The primary outcomes included visual analogue score (VAS), WOMAC pain, WOMAC stiffness, WOMAC function and lequesne index.

Result

Seven trials involving 545 patients were included. Compared with the control group, Boswellia and its extract may relieve the pain [VAS: (WMD -8.33; 95% CI -11.19, − 5.46; P<0.00001); WOMAC pain: (WMD -14.22; 95% CI -22.34, − 6.09; P = 0. 0006)] and stiffness [WOMAC stiffness: (WMD -10.04; 95% CI -15.86, − 4.22; P = 0. 0007)], and improve the joint’s function [WOMAC function: (WMD -10.75; 95% CI -15.06, − 6.43; P<0. 00001); lequesne index: (WMD -2.27; 95% CI -3.08, − 1.45; P<0. 00001)].

Conclusion

Based on current evidence, Boswellia and its extract may be an effective and safe treatment option for patient with OA, and the recommended duration of treatment with Boswellia and its extract is at least 4 weeks.

Conditional Recommendations for Specific Dietary Ingredients as an Approach to Chronic Musculoskeletal Pain: Evidence-Based Decision Aid for Health Care Providers, Participants, and Policy Makers

OBJECTIVE

Approximately 55-76% of Service members use dietary supplements for various reasons; although such use has become popular for a wide range of pain conditions, decisions to use supplements are often driven by information that is not evidence-based. This work evaluates whether the current research on dietary ingredients for chronic musculoskeletal pain provides sufficient evidence to inform decisions for practice and self-care, specifically for Special Operations Forces personnel.

METHODS

A steering committee convened to develop research questions and factors required for decision-making. Key databases were searched through August 2016. Eligible systematic reviews and randomized controlled trials were assessed for methodological quality. Meta-analysis was applied where feasible. GRADE was used to determine confidence in the effect estimates. A decision table was constructed to make evidence-informed judgments across factors required for decision-making, and recommendations were made for practice and self-care use.

RESULTS

Nineteen dietary ingredients were included. Conditional evidence-based recommendations were made for the use of avocado soybean unsaponifiables, capsaicin, curcuma, ginger, glucosamine, melatonin, polyunsaturated fatty acids, and vitamin D. In these cases, desirable effects outweighed undesirable effects, but there was uncertainty about the trade-offs, either because the evidence was low quality or because benefits and downsides were closely balanced.

CONCLUSIONS

The evidence showed that certain dietary ingredients, when taken as part of a balanced diet and/or as a supplement (e.g., pill, tablet, capsule, cream), may alleviate musculoskeletal pain with no to minimal risk of harm. This finding emphasizes and reinforces the critical importance of shared decision-making between Operators and their health care providers.

Dietary Ingredients Requiring Further Research Before Evidence-Based Recommendations Can Be Made for Their Use as an Approach to Mitigating Pain

OBJECTIVE

Approximately 55-76% of Service members use dietary supplements for various reasons; although such use has become popular, decisions are often driven by information that is not evidence-based. This work evaluates whether current research on dietary ingredients for chronic musculoskeletal pain provides sufficient evidence to inform decisions for practice and self-care, specifically for Special Operations Forces personnel.

METHODS

A steering committee convened to develop research questions and factors required for decision-making. Key databases were searched through August 2016. Eligible systematic reviews and randomized controlled trials were assessed for methodological quality. Meta-analysis was applied where feasible. Grading of Recommendations, Assessment, Development and Evaluation was used to determine confidence in the effect estimates. The committee used a decision table to make evidence-informed judgments across decision-making factors and recommendations for practice and self-care use.

RESULTS

Nineteen dietary ingredients were assessed. No recommendations were given for boswellia, ginger, rose hip, or s-adenosyl-L-methionine (SAMe); specifically, although ginger can be obtained via food, no recommendation is provided for use as a supplement due to unclear research. Further, there were insufficient strong research on boswellia and SAMe and possible compliance issues (i.e., high number of capsules required daily) associated with rose hip.

CONCLUSIONS

No recommendations were made when the evidence was low quality or trade-offs were so closely balanced that any recommendation would be too speculative. Research recommendations are provided to enhance the quality and body of evidence for the most promising ingredients. Clinicians and those with chronic pain can rely on evidence-based recommendations to inform their decisions.

Curcumin in Autoimmune and Rheumatic Diseases

Over recent decades, many clinical trials on curcumin supplementation have been conducted on various autoimmune diseases including osteoarthritis, type 2 diabetes, and ulcerative colitis patients. This review attempts to summarize the highlights from these clinical trials. The efficacy of curcumin either alone or in conjunction with existing treatment was evaluated. Sixteen clinical trials have been conducted in osteoarthritis, 14 of which yielded significant improvements in multiple disease parameters. Eight trials have been conducted in type 2 diabetes, all yielding significant improvement in clinical or laboratory outcomes. Three trials were in ulcerative colitis, two of which yielded significant improvement in at least one clinical outcome. Additionally, two clinical trials on rheumatoid arthritis, one clinical trial on lupus nephritis, and two clinical trials on multiple sclerosis resulted in inconclusive results. Longer duration, larger cohort size, and multiple dosage arm trials are warranted to establish the long term benefits of curcumin supplementation. Multiple mechanisms of action of curcumin on these diseases have been researched, including the modulation of the eicosanoid pathway towards a more anti-inflammatory pathway, and the modulation of serum lipid levels towards a favorable profile. Overall, curcumin supplementation emerges as an effective therapeutic agent with minimal-to-no side effects, which can be added in conjunction to current standard of care.

Efficacy of curcumin and Boswellia for knee osteoarthritis: Systematic review and meta-analysis

PURPOSE

The unfavorable safety profiles of commonly prescribed knee osteoarthritis (OA) treatments have led clinicians and patients to seek safer alternatives. Research has suggested that curcuminoid and boswellia formulations could moderate key inflammatory pathways that are associated with worsening symptoms and disease progression. We conducted a systematic review and meta-analysis to assess the efficacy and safety of these treatments vs. placebo or NSAIDs for knee OA.

METHODS

We searched Medline, EMBASE, Google Scholar, Web of Science and the Cochrane database from inception to February 21, 2018. We also hand searched reference lists and reviewed conference proceedings. We included randomized clinical trials (RCTs) comparing curcuminoid or boswellia formulations with placebo or NSAIDs for knee OA. We calculated standardized mean differences (SMD) or risk ratios (RR) for all relevant outcomes. Meta-analyses were conducted using random effects models. Heterogeneity was assessed using the I2 statistic.

RESULTS

Eleven RCTs (N = 1009) were eligible for analysis. Study quality was low overall, and most included RCTs were conducted on fewer than 100 participants. Both curcuminoid and boswellia formulations were statistically significantly more effective than placebo for pain relief and functional improvement. There were no significant differences between curcuminoids or boswellia and placebo in safety outcomes. Curcuminoids showed no statistically significant differences in efficacy outcomes compared to NSAIDs; patients receiving curcuminoids were significantly less likely to experience gastrointestinal adverse events. No RCTs compared boswellia against approved NSAIDs.

CONCLUSIONS

The results of our study suggest that curcuminoid and boswellia formulations could be a valuable addition to the knee OA treatment regimens by relieving symptoms while reducing safety risks. The current body of evidence is not adequate in size or quality to make any meaningful clinical practice recommendations. Further research through large, high quality RCTs probably investigating the synergistic effect of these products with other OA treatments is warranted.

Oral curcumin supplementation improves fine motor function in the middle-aged rhesus monkey

Aged individuals experience decreased fine motor function of the hand and digits, which could result, in part, from the chronic, systemic state of inflammation that occurs with aging. Recent research for treating age-related inflammation has focused on the effects of nutraceuticals that have anti-inflammatory properties. One particular dietary polyphenol, curcumin, the principal curcuminoid of the spice turmeric, has been shown to have significant anti-inflammatory effects and there is mounting evidence that curcumin may serve to reduce systemic inflammation. Therefore, it could be useful for alleviating age-related impairments in fine motor function. To test this hypothesis we assessed the efficacy of a dietary intervention with a commercially available optimized curcumin to ameliorate or delay the effects of aging on fine motor function of the hand of rhesus monkeys. We administered oral daily doses of curcumin or a control vehicle to 11 monkeys over a 14- to 18-month period in which they completed two rounds of fine motor function testing. The monkeys receiving curcumin were significantly faster at retrieving a food reward by round 2 of testing than monkeys receiving a control vehicle. Further, the monkeys receiving curcumin demonstrated a greater degree of improvement in performance on our fine motor task by round 2 of testing than monkeys receiving a control vehicle. These findings reveal that fine motor function of the hand and digits is improved in middle-aged monkeys receiving chronic daily administration of curcumin.

The effects of curcuminoids on musculoskeletal pain: a systematic review

BACKGROUND

Western countries are increasingly using complementary and alternative medicine (CAM) to assist with relieving ailments. Turmeric, from the ginger family Zingiberaceae, has a history of use for medicinal purposes. The polyphenols found in turmeric (curcuminoids) have demonstrated anti-inflammatory and pain relieving properties. With the use of CAMs increasing, it is important for the effectiveness of curcuminoids to be established.

OBJECTIVES

To identify the effectiveness of the use of curcuminoids for the amelioration of musculoskeletal pain.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Persons experiencing musculoskeletal pain, including experimentally induced musculoskeletal pain.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

The current review considered studies that evaluated the use of curcuminoids.

TYPES OF CONTROLS

Any form including placebo, treatment as usual or before and after measurements.

TYPES OF STUDIES

Both experimental and epidemiological study designs including randomized controlled trials (RCTs), non-RCTs, quasi-experimental and before and after studies were eligible for consideration in this review. Studies published in English were considered without date restriction.

OUTCOMES

The current review considered studies that included measurement of pain. Outcome measures included visual analog scales, and/or pain questionnaires. Secondary outcome measures of functionality (activities of daily living and range of motion) were included. Any data provided on adverse events were considered.

SEARCH STRATEGY

The databases PubMed, CINAHL, Embase and ProQuest were searched in March 2015 (and updated in April 2016) using the Joanna Briggs Institute (JBI) three-step search strategy. The reference lists of identified articles were reviewed for additional studies.

METHODOLOGICAL QUALITY

Papers selected were assessed by two independent reviewers using standardized instruments from the JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI).

DATA EXTRACTION

Data were extracted using the data extraction tool from JBI-MAStARI. Data extracted included details about the populations, interventions, study methods and outcomes.

DATA SYNTHESIS

Narrative and tabular synthesis was conducted. Meta-analysis was precluded due to methodological and clinical heterogeneity across all included studies.

RESULTS

Thirteen studies with a combined total of 1101 participants were included. Three studies of limited sample size examined the effects of curcuminoids compared with the use of placebo on musculoskeletal pain, with one study showing a statistically significant effect. Four studies examined the effects of curcuminoids compared with non-selective non-steroidal anti-inflammatory drugs on musculoskeletal pain. Two of these four studies were non-inferiority studies showed that the use of both curcuminoids and ibuprofen were associated with a similar significant reduction in pain over the study durations of four and six weeks, respectively, with curcuminoid use non-inferior to the use of ibuprofen over the study durations. Six studies investigated presentations of curcuminoid-containing herbomineral mixtures versus placebo or active controls.

CONCLUSION

There is insufficient evidence to recommend that curcuminoids be considered for relieving pain and improving function in musculoskeletal pain conditions. This finding needs to be considered in the context of limitations imposed by the variability in the quality of studies, small sample sizes, short duration of interventions, a gender-bias toward females, absence of long-term data extraction and small number of relevant studies.

Nutraceutical Supplements in the Management and Prevention of Osteoarthritis

Nutraceuticals are dietary compounds which have a role in the balance of anabolic and catabolic signals in joints. Their regulatory function on homeostasis of cartilage metabolism nutraceuticals is increasingly considered for the management and, above all, the prevention of osteoarthritis (OA). OA is a degenerative disease characterized by cartilage and synovium inflammation that can cause joint stiffness, swelling, pain, and loss of mobility. It is a multifactorial disease and, due to the great percentage of people suffering from it and the general increase in life expectancy, OA is considered as one of the most significant causes of disability in the world. OA impairs the structural integrity of articular cartilage that greatly depends on a balance between the anabolic and catabolic processes which occur in chondrocytes and synovial fluid of the joints, therefore the integration with nutraceutical compounds in diet increases the treatment options for patients with established OA beyond traditional rehabilitation, medications, and surgical strategies. In our review, with respect to the current literature, we highlight some of many existing nutraceutical compounds that could be used as integrators in a daily diet thanks to their easy availability, such as in olive oil, fish oil, and botanical extracts used as non-pharmacologic treatment.

Gastroretentive Matrix Tablets of Boswellia Oleogum Resin: Preparation, Optimization, In Vitro Evaluation, and Cytoprotective Effect on Indomethacin-Induced Gastric Ulcer in Rabbits

Currently available anti-ulcer drugs suffer from serious side effects which limited their uses and prompted the need to search for a safe and efficient new anti-ulcer agent. Boswellia gum resin (BR) emerged as a safe, efficient, natural, and economic potential cytoprotective agent. Thus, it is of medical importance to develop gastroretentive (GR) formulations of BR to enhance its bioavailability and anti-ulcer efficacy. Early attempts involved the use of organic solvents and non-applicability to large-scale production. In this study, different tablet formulations were prepared by simple direct compression combining floating and bioadhesion mechanisms employing hydroxypropyl methylcellulose (HPMC), sodium carboxymethyl cellulose (SCMC), pectin (PC), and/or carbopol (CP) as bioadhesive polymers and sodium bicarbonate (SB) as a gas former. The prepared tablets were subjected for assessment of swelling, floating, bioadhesion, and drug release in 0.1 N HCl. The optimized GR formulation was examined for its protective effect on the gastric ulcer induced by indomethacin in albino rabbits compared with lactose tablets. The obtained results disclosed that swelling, floating, bioadhesion, and drug release of the GR tablets of BR depend mainly on the nature of the matrix and the ratio of polymer combinations. Moreover, a combination of SCMC-CP in a ratio of 2:1 (SCP21) exhibited desirable floating, bioadhesion, swelling, and extended drug release. Also, a 6-h pretreatment with SCP21 tablets decreased the severity of inflammation and number of bleeding spots among ulcer-induced rabbits in comparison to those treated with lactose tablets.

Oral herbal therapies for treating osteoarthritis

BACKGROUND

Medicinal plant products are used orally for treating osteoarthritis. Although their mechanisms of action have not yet been elucidated in full detail, interactions with common inflammatory mediators provide a rationale for using them to treat osteoarthritic complaints.

OBJECTIVES

To update a previous Cochrane review to assess the benefits and harms of oral medicinal plant products in treating osteoarthritis.

SEARCH METHODS

We searched electronic databases (CENTRAL, MEDLINE, EMBASE, AMED, CINAHL, ISI Web of Science, World Health Organization Clinical Trials Registry Platform) to 29 August 2013, unrestricted by language, and the reference lists from retrieved trials.

SELECTION CRITERIA

Randomised controlled trials of orally consumed herbal interventions compared with placebo or active controls in people with osteoarthritis were included. Herbal interventions included any plant preparation but excluded homeopathy or aromatherapy products, or any preparation of synthetic origin.

DATA COLLECTION AND ANALYSIS

Two authors used standard methods for trial selection and data extraction, and assessed the quality of the body of evidence using the GRADE approach for major outcomes (pain, function, radiographic joint changes, quality of life, withdrawals due to adverse events, total adverse events, and serious adverse events).

MAIN RESULTS

Forty-nine randomised controlled studies (33 interventions, 5980 participants) were included. Seventeen studies of confirmatory design (sample and effect sizes pre-specified) were mostly at moderate risk of bias. The remaining 32 studies of exploratory design were at higher risk of bias. Due to differing interventions, meta-analyses were restricted to Boswellia serrata (monoherbal) and avocado-soyabean unsaponifiables (ASU) (two herb combination) products.Five studies of three different extracts from Boswellia serrata were included. High-quality evidence from two studies (85 participants) indicated that 90 days treatment with 100 mg of enriched Boswellia serrata extract improved symptoms compared to placebo. Mean pain was 40 points on a 0 to 100 point VAS scale (0 is no pain) with placebo, enriched Boswellia serrata reduced pain by a mean of 17 points (95% confidence interval (CI) 8 to 26); number needed to treat for an additional beneficial outcome (NNTB) 2; the 95% CIs did not exclude a clinically significant reduction of 15 points in pain. Physical function was 33 points on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) 0 to 100 point subscale (0 is no loss of function) with placebo, enriched Boswellia serrata improved function by 8 points (95% CI 2 to 14); NNTB 4. Assuming a minimal clinically important difference of 10 points, we cannot exclude a clinically important benefit in some people. Moderate-quality evidence (one study, 96 participants) indicated that adverse events were probably reduced with enriched Boswellia serrata (18/48 events versus 30/48 events with placebo; relative risk (RR) 0.60, 95% CI 0.39 to 0.92). Possible benefits of other Boswellia serrata extracts over placebo were confirmed in moderate-quality evidence from two studies (97 participants) of Boswellia serrata (enriched) 100 mg plus non-volatile oil, and low-quality evidence from small single studies of a 999 mg daily dose of Boswellia serrata extract and 250 mg daily dose of enrichedBoswellia serrata. It was uncertain if a 99 mg daily dose of Boswellia serrata offered benefits over valdecoxib due to the very low-quality evidence from a small single study. It was uncertain if there was an increased risk of adverse events or withdrawals with Boswellia serrata extract due to variable reporting of results across studies. The studies reported no serious adverse events. Quality of life and radiographic joint changes were not measured.Six studies examined the ASU product Piasclidine®. Moderate-quality evidence from four studies (651 participants) indicated that ASU 300 mg produced a small and clinically questionable improvement in symptoms, and probably no increased adverse events compared to placebo after three to 12 months treatment. Mean pain with placebo was 40.5 points on a VAS 0 to 100 scale (0 is no pain), ASU 300 mg reduced pain by a mean of 8.5 points (95% CI 1 to 16 points); NNTB 8. ASU 300 mg improved function (standardised mean difference (SMD) -0.42, 95% CI -0.73 to -0.11). Function was estimated as 47 mm (0 to 100 mm scale, where 0 is no loss of function) with placebo, ASU 300 mg improved function by a mean of 7 mm (95% CI 2 to 12 mm); NNTB 5 (3 to 19). There were no differences in adverse events (5 studies, 1050 participants) between ASU (53%) and placebo (51%) (RR 1.04, 95% CI 0.97 to 1.12); withdrawals due to adverse events (1 study, 398 participants) between ASU (17%) and placebo (15%) (RR 1.14, 95% CI 0.73 to 1.80); or serious adverse events (1 study, 398 participants) between ASU (40%) and placebo (33%) (RR 1.22, 95% CI 0.94 to 1.59). Radiographic joint changes, measured as change in joint space width (JSW) in two studies (453 participants) did not differ between ASU 300 mg treatment (-0.53 mm) and placebo (-0.65 mm); mean difference of -0.12 (95% CI -0.43 to 0.19). Moderate-quality evidence from a single study (156 participants) confirmed possible benefits of ASU 600 mg over placebo, with no increased adverse events. Low-quality evidence (1 study, 357 participants) indicated there may be no differences in symptoms or adverse events between ASU 300 mg and chondroitin sulphate. Quality of life was not measured.All other herbal interventions were investigated in single studies, limiting conclusions. No serious side effects related to any plant product were reported.

AUTHORS' CONCLUSIONS

Evidence for the proprietary ASU product Piasclidine® in the treatment of osteoarthritis symptoms seems moderate to high for short term use, but studies over a longer term and against an apparently active control are less convincing. Several other medicinal plant products, including extracts of Boswellia serrata, show trends of benefits that warrant further investigation in light of the fact that the risk of adverse events appear low.There is no evidence that Piasclidine® significantly improves joint structure, and limited evidence that it prevents joint space narrowing. Structural changes were not tested for with any other herbal intervention.Further investigations are required to determine optimum daily doses producing clinical benefits without adverse events.

Postconcussion syndrome: a review of pathophysiology and potential nonpharmacological approaches to treatment

The incidence of all-cause concussions in the United States is estimated to range from 1.6 to 3.8 million annually, with the reported number of sport- or recreation-related concussions increasing dramatically, especially in youth sports.(1,2) Additionally, the use of roadside bombs in Iraq and Afghanistan has propelled the incidence of concussion and other traumatic brain injuries to the highest levels ever encountered by the US military. As a result, there has also been a marked increase in postconcussion syndrome (PCS) and the associated cognitive, emotional, and memory disabilities associated with the condition. Unfortunately, however, there have been no significant advancements in the understanding or treatment of PCS for decades. The current management of PCS mainly consists of rest, reduction of sensory inputs, and treating symptoms as needed. Recently, researchers investigating the underlying mechanisms of PCS have proposed that activation of the immune inflammatory response may be an underlying pathophysiology that occurs in those who experience prolonged symptoms after a concussion. This article reviews the literature and summarizes the immune inflammatory response known as immunoexcitotoxicity. This article also discusses the use of nonpharmacological agents for the management of PCS that directly address this underlying mechanism.

Nutritional interventions to prevent and treat osteoarthritis. Part II: focus on micronutrients and supportive nutraceuticals

Osteoarthritis (OA) is the most common cause of musculoskeletal disability in the elderly, and it places an enormous economic burden on society, which will remain a major health care challenge with an aging population. Management of OA is primarily focused on palliative relief using agents such as nonsteroidal anti-inflammatory drugs (NSAID) and analgesics. However, such an approach is limited by a narrow therapeutic focus that fails to address the progressive and multimodal nature of OA. Given the favorable safety profile of most nutritional interventions, identifying disease-modifying pharmaconutrients capable of improving symptoms and also preventing, slowing, or even reversing the degenerative process in OA should remain an important paradigm in translational and clinical research. The goals of pharmaconutrition for metabolic optimization are to drive biochemical reactions in a desired direction and to meet health condition-specific metabolic demands. Applying advances in nutritional science to musculoskeletal medicine remains challenging, given the fluid and dynamic nature of the field, along with a rapidly developing regulatory climate over manufacturing and commerce requirements. The purpose of this article is to review the available literature on effectiveness and potential mechanism for OA of micronutrient vitamins; minerals; glycosaminoglycans; avocado-soybean unsaponifiable fractions; methylsulfonylmethane; s-adenosylmethionine; undenatured and hydrolyzed collagen preparations; phytoflavonoid compounds found in fruits, vegetables, spices, teas, and nuts; and other nutrients on the horizon. There also is a discussion on the concept of rational polysupplementation via the strategic integration of multiple nutraceuticals with potential complementary mechanisms for improving outcomes in OA. As applied nutritional science evolves, it will be important to stay on the forefront of proteomics, metabolomics, epigenetics, and nutrigenomics, because they hold enormous potential for developing novel therapeutic and prognostic breakthroughs in many areas of medicine, including OA.

Evidence of effectiveness of herbal medicinal products in the treatment of arthritis. Part I: Osteoarthritis

Herbal medicinal products (HMPs) are used in a variety of oral and topical forms for the treatment of osteoarthritis. The aim of this study was to update a previous systematic review published in 2000. We searched electronic databases (MEDLINE, EMBASE, CISCOM, AMED, CINAHL, Cochrane registers) to June 2007, unrestricted by date or language, and included randomized controlled trials that compared HMPs with inert (placebo) or active controls in patients with osteoarthritis. Five reviewers contributed to data extraction. Disagreements were discussed and resolved by consensus with reference to Cochrane guidelines and advice from the Cochrane Collaboration.Thirty-five studies (30 studies identified for this review update, and 5 studies included in the original review) evaluating the effectiveness of 22 HMPs were included. However, due to differing HMPs, interventions, comparators, and outcome measures, meta-analysis was restricted to data from studies of three HMPs: topical capsaicin, avocado-soybean unsaponifiables, and the Chinese herbal mixture SKI306X showed benefit in the alleviation of osteoarthritic pain.Several studies investigating products from devil's claw, and a powder from rose hip and seed, reported favorable effects on osteoarthritic pain, whereas two studies of a willow bark extract returned disparate results. Three studies of Phytodolor N(R) were of limited use because doses and measures were inconsistent among trials. The remaining single studies for each HMP provided moderate evidence of effectiveness. No serious side effects were reported with any herbal intervention.Despite some evidence, the effectiveness of none of the HMPs is proven beyond doubt. The obvious potential benefits of HMPs in the treatment of osteoarthritis are reduced reliance on synthetic medications with the associated risks of harmful adverse events, but further clinical trials are necessary before HMPs can be adopted in osteoarthritis treatment guidelines.

Natural antiinflammatory agents for pain relief in athletes

Most athletes experience musculoskeletal injuries during their sports activity that require rest at a minimum, and occasionally injuries are severe enough to necessitate surgical repair. Neurosurgeons are often consulted for athletically sustained injuries and prescribe medications for the associated pain. The use of both over-the-counter and prescription nonsteroidal medications is frequently recommended, but recent safety concerns must now be considered. The authors discuss the biochemical pathways of nonsteroidal drugs and review the potentially serious side effects of these medications. They also review the use of natural supplements, which may be a safer, and often as effective, alternative treatment for pain relief.