Rick Marinelli, ND, MAcOM
January 13, 2005
News reports the last few months on the increased cardiovascular risks associated with taking NSAIDs is hardly a news flash for those progressive doctors doing Prolotherapy and other cutting edge pain therapies. Ever since Merck took rofecoxib (Vioxx) off the market in September, it seems one carboxylic derived NSAID after another has fallen as evidence of or suggestion of injury has been associated with their use including voldecoxib (Bexstra), celecoxib (Celebrex), and now naproxen (Naprosyn, Aleve). The public and uninformed doctors are now scrambling for alternatives to taking these drugs when the answers have been before us for a long time.
The primary reason knowledgeable doctors have not wanted their patients taking these NSAIDs is the inhibiting effect of these drugs on healing ligaments, tendons, cartilage. While not all NSAIDs are created equal there is significant animal data to indicate a general inhibition in wound repair and collagen synthesis in the presence of these drugs. Ligaments have been shown to have less tensile strength, articular cartilage is less robust, and tendon strength is inhibited when chronically exposed to NSAIDs in these classes or when these NSAIDs are taken after an acute injury. Collagen synthesis and remodeling of wounded areas is how our bodies have such remarkable self-healing capabilities. If this becomes unbalanced, as with the inhibition of collagen synthesis in the presence of carboxylic derived NSAIDs, then this lack of healing quickly gives way to accelerated tissue breakdown of the collagen matrix, leading to degeneration of the tendons (tendinopathy), of the cartilage (Osteoarthritis), and of the surrounding ligaments (joint instability). In part this occurs because there is now an imbalance of the collagen remodeling with a definite trend toward collagen breakdown instead of repair and regeneration. To be sure this may be associated with injury, age, osteoarthritis, or an immune-mediated type of collagen vascular disease like rheumatoid arthritis as well as nutrient deficiencies and other metabolic disturbances.
So What Are We To Do?
There are an increasing number of studies on the efficacy and safety of Prolotherapy or regenerative injection therapy in soft tissue pain, joint instability, tendinopathies, growth factors the effects of Prolotherapy will improve to an even greater degree. There is also an increasing body of evidence to support the long known effects of diet, nutritional supplements, herbal medicine, and exercise on the healing of collagen and specifically on osteoarthritis. Let’s just briefly mention the best studied of these.
Ever since the Lancet study in 1999 on oral glucosamine for knee osteoarthritis, it has been clear that our observations were correct. Many doctors have been using glucosamine for years prior to this study showing that not only are functional symptoms greatly improved (e.g. pain-free walking time) but in some cases cartilage regrowth and an increase in thickness of the cartilage was able to be seen on xray. Similar results have been associated with the oral ingestion of other GAGs (glycosaminoglycans) such as chondroitin (more chondroprotective than regenerative), bovine trachea cartilage, green-lipped muscle, etc. Dr. Reeves knee prolotherapy studies have shown similarly impressive results with only the use of local anesthetic and glucose! Many of us have used glucosamine for years as an addition to our Prolotherapy solutions in the hope of even better results. I believe future studies will show there is an increased benefit with this approach for most patients.
Type in fish oil on the query line of the National Library of Medicine (Pub Med) and you get almost 10,000 hits. To say there are many articles on the benefits of taking fish oil as a supplement is a gross understatement. In addition to its well-recognized effects on cardiovascular risks (decreases in strokes, blood pressure, blood viscosity, triglycerides, vascular inflammation), you will find studies suggesting benefits in osteoarthritis, soft tissue pain and inflammation, and reduction of the breakdown of the collagen matrix we have been talking about.
Despite recent flawed studies on the negative effects of antioxidants, the majority of studies show an overall reduction in cancer, degenerative diseases, and cardiovascular mortality from the use of antioxidant supplements. Clinically, this is especially apparent in osteoarthritis. Whole food antioxidants such as fish, green tea, berries, chocolate, garlic, and nuts are especially easy additions to one’s diet.
Historically, in traditional herbal medicine many formulae have been successfully used. Prominent among these are those containing the herbs ginger, boswellia, angelica dahurica, salvia, atractylodes, lycium, bupleurum, poria, etc. The complexity of these herbal medicines and the lack of research funding (like prolotherapy) has hampered understanding from a scientific perspective. These herbal medicines will gain prominence in use as they are better understood. Many important discoveries in pharmacology have been associated with the study of traditional herbal medicine prescriptions.
The lack of exercise in our culture is certainly a huge problem with soaring rates of obesity, cardiovascular mortality, and diabetes as a result. This is hardly news to prolotherapy doctors who along with others have been advocating and prescribing exercise to their patients from the beginning. In older athletic patient, or with “weekend warriors” there are greater challenges with optimizing the amount of exercise. Many of these folks also have excessive collagen breakdown due to exceeding their bodies’ repair abilities. This repair function is often improved with the addition of glucosamine, fish oil, antioxidants, and herbal medicine and a more reasonable and varied exercise approach. Often, there are deficiencies of anabolic repair (hormones such as Testosterone, Growth Hormone, thyroid) inhibition by metabolic factors (excess sugar intake, insulin resistance, cytokine imbalance) or a combination of these factors. An experienced practitioner can help to sort these out. Overall though, more exercise is better!
From the preceding discussion, I think it is clear there are many good natural alternatives to the use of NSAIDs. If you are a patient, seek out those practitioners (like most that are listed here) who have experience in these areas. If you are a doctor that would like to use these approaches but have little experience, please seek out some of the excellent continuing education courses offered. Your patients will be glad you did.