Joint Health Supplements - Fact or Fiction?
Osteoarthritis is a prevalent disease, so correspondingly the desire for a pharmaceutical cure to joint aging is equally strong. Family members, friends, colleagues, doctors, websites, pharmacist will all swear by a product, telling you that this pill or that injection changed their lives and “Really Work!”. But through this cacophony of advice, do any of these products truly work or is it purely a placebo response to a well-crafted sales pitch?
Below is a summary of the evidence for several common; oral, injectable or topical joint health supplements that are said to reduce arthritic pain and slow down joint disease.
Glucosamine Sulfate is a naturally occurring amino sugar that is found in the fluid that fills joint spaces in the human body. In the supplement industry it is produced and sold in many forms, but the medically recognised effective and researched version is called, patented crystalline glucosamine sulfate (pCGS)1, and is often paired with the substance Chondroitin. Several high-moderate quality studies found no significant difference in pain, function or reduced joint space narrowing, when compared to placebo 2, 3, 4. Several moderate-low quality studies showed a significant reduction in joint space narrowing, decreased anti-inflammatory use, and decreased need for joint replacement surgery 5, 6, 7. The Cochrane review produced in 2009 for the use of Glucosamine, is consistent with these findings, stating that, Glucosamine might help, but the high-quality evidence suggests it probably doesn’t.
Chondroitin Sulfate is a naturally occurring sulphated glycosaminoglycan found in joint cartilage and bone. In supplement form is normally sourced from animal cartilage and is often paired with Glucosamine Sulfate. There are a small number of moderate-low quality small studies which found Chondroitin Sulfate to significantly reduce joint space narrowing, but did not reduce anti-inflammatory use and was no better than placebo in reducing pain 3. One moderate quality study that suggests Chondroitin Sulfate improves both pain and function 7. The Cochrane review for the use of Chondroitin Sulfate written in 2013 states that it might give some short-term reduction in pain, and reduce the loss of joint space compared to placebo, but the amount of improvement is very small and most of the evidence is of poor quality.
Various Herbs, Spices and Natural Remedies have been said to improve or maintain joint health, including; avocado-soybean unsaponifiables, turmeric, curcumin, capsaincin, Boswellia serrata extract and ginger. Tumeric, Curcumin and Ginger have been found in several small low-moderate quality studies to reduce pain and improve function 8, 9, 10, 11. These products have been researched in a laboratory setting with some promising results, but further high quality human studies are needed. Avocado-soybean unsaponifiables and Bowellia serrata extract might have a small effect on pain and function when compared to placebo, according to the 2014, Cochrane review, however recent studies have shown them to have no statistically significant effect 12.
Omega-3 fatty acids are found in foods such as fish and flaxseeds and are the main compound in fish-oil supplements. Several moderate quality studies have found that omega-3 fatty acids might be helpful in reducing pain in those with osteoarthritis, especially combined with the use of Glucosamine Sulfate 13, 14. However, it has long been shown that omega-3 fatty acids may be helpful In managing pain conditions in general, and there is no quality evidence to show that this reduction in pain has anything to do with improvements in joint health.
Joint injections for the treatment of osteoarthritis have also become increasingly popular. In this review, we will not cover corticosteroid injections for pain and inflammation, but examine the evidence behind joint health injections such as Synvisc and Durolane.
Synvisc, Hya-Joint Plus and Durolane are commercial names for the gel-like viscosupplement hyaluronan (or hyaluronic acid), an anionic non-sulfated glycosaminoglycans like that found naturally in joints and other parts of the body. It is synthetically produced and delivered as an injected, and through to provide lubrication in diseased joints. Several moderate quality studies have shown that Synvisc and Hya-Joint Plus may decrease pain in those with osteoarthritis for up to six months or maybe longer 15, 16, 17. However, good quality research is still needed to prove these findings. Durolane was found in several low-moderate quality studies to decrease pain and stiffness and improve function 18, perhaps better than corticosteroid injections, but was found in further studies to be no better than placebo injections 19.
To our knowledge there are no high-quality studies examining the use of topical herbal products for joint health, and of the studies that do exist the findings are unclear. The Cochrane review written in 2013, suggests that Arnica gel and Confrey extract gel might be helpful, but the research is of low quality. Chinese Herbal Rubs have no effect on joint health or osteoarthritis symptoms 12. Capsaincin meanwhile, has not only been found to have no effect on pain or joint health, but is also dangerous with many patients reporting negative harmful side effects.
In summary, when looking at the current research for all these joint health supplements, we can only say that some of these ‘might’ help a small amount with symptom relief compared to placebo and ‘might’ but probably don’t help with physical joint health.
Here is the sticky question…… Let’s lay out the ethical argument.
Most people have signs of joint disease.
Whether they have pain or loss of function from this joint disease is highly variable and based on several anatomical and psychological factors.
Pain is a complex, biopsychosocial process and is highly affected by beliefs and expectations.
If we believe a supplement works (even if it doesn’t), we can get a placebo effect.
The result is a decrease in pain and an improvement in function so does it really matter how this effect is achieved?
Should we stick to what science shows us or accept the change we feel and not question the source?
References:
1. Kucharz, E. J., Kovalenko, V., Szántó, S., Bruyère, O., Cooper, C., & Reginster, J. Y. (2016). A review of glucosamine for knee osteoarthritis: why patented crystalline glucosamine sulfate should be differentiated from other glucosamines to maximize clinical outcomes. Current medical research and opinion, 32(6), 997-1004.
2. Roman‐Blas, J. A., Castañeda, S., Sánchez‐Pernaute, O., Largo, R., & Herrero‐Beaumont, G. (2017). Combined Treatment With Chondroitin Sulfate and Glucosamine Sulfate Shows No Superiority Over Placebo for Reduction of Joint Pain and Functional Impairment in Patients With Knee Osteoarthritis: A Six‐Month Multicenter, Randomized, Double‐Blind, Placebo‐Controlled Clinical Trial. Arthritis & Rheumatology, 69(1), 77-85.
3. Fransen, M., Agaliotis, M., Nairn, L., Votrubec, M., Bridgett, L., Su, S., ... & Woodward, M. (2015). Glucosamine and chondroitin for knee osteoarthritis: a double-blind randomised placebo-controlled clinical trial evaluating single and combination regimens. Annals of the rheumatic diseases, 74(5), 851-858.
4. Wandel, S., Jüni, P., Tendal, B., Nüesch, E., Villiger, P. M., Welton, N. J., ... & Trelle, S. (2010). Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. Bmj, 341, c4675.
5. Bruyère, O., Altman, R. D., & Reginster, J. Y. (2016, February). Efficacy and safety of glucosamine sulfate in the management of osteoarthritis: Evidence from real-life setting trials and surveys. In Seminars in arthritis and rheumatism (Vol. 45, No. 4, pp. S12-S17). WB Saunders.
6. Runhaar, J., Deroisy, R., van Middelkoop, M., Barretta, F., Barbetta, B., Oei, E. H., ... & Reginster, J. Y. (2016, February). The role of diet and exercise and of glucosamine sulfate in the prevention of knee osteoarthritis: Further results from the PRevention of knee Osteoarthritis in Overweight Females (PROOF) study. In Seminars in arthritis and rheumatism (Vol. 45, No. 4, pp. S42-S48). WB Saunders.
7. Hochberg, M. C., Martel-Pelletier, J., Monfort, J., Möller, I., Castillo, J. R., Arden, N., ... & Henrotin, Y. (2015). Combined chondroitin sulfate and glucosamine for painful knee osteoarthritis: a multicentre, randomised, double-blind, non-inferiority trial versus celecoxib. Annals of the rheumatic diseases, annrheumdis-2014.
8. Ha, L. H., & Nesteby, A. (2017). The Effects of Curcumin in Decreasing Pain in Patients with Osteoarthritis.
9. Daily, J. W., Yang, M., & Park, S. (2016). Efficacy of turmeric extracts and curcumin for alleviating the symptoms of joint arthritis: a systematic review and meta-analysis of randomized clinical trials. Journal of medicinal food, 19(8), 717-729.
10. Bartels, E. M., Folmer, V. N., Bliddal, H., Altman, R. D., Juhl, C., Tarp, S., ... & Christensen, R. (2015). Efficacy and safety of ginger in osteoarthritis patients: a meta-analysis of randomized placebo-controlled trials. Osteoarthritis and cartilage, 23(1), 13-21.
11. Long, L., Soeken, K., & Ernst, E. (2001). Herbal medicines for the treatment of osteoarthritis: a systematic review. Rheumatology, 40(7), 779-793.
12. Cameron, M., & Chrubasik, S. (2014). Oral herbal therapies for treating osteoarthritis. The Cochrane Library.
13. Yates, C. M., Calder, P. C., & Rainger, G. E. (2014). Pharmacology and therapeutics of omega-3 polyunsaturated fatty acids in chronic inflammatory disease. Pharmacology & therapeutics, 141(3), 272-282.
14. Gruenwald, J., Petzold, E., Busch, R., Petzold, H. P., & Graubaum, H. J. (2009). Effect of glucosamine sulfate with or without omega-3 fatty acids in patients with osteoarthritis. Advances in therapy, 26(9), 858-871.
15. Boutefnouchet, T., Puranik, G., Holmes, E., & Bell, K. M. (2017). Hylan GF-20 Viscosupplementation in the Treatment of Symptomatic Osteoarthritis of the Knee: Clinical Effect Survivorship at 5 Years. Knee surgery & related research, 29(2), 129.
16. Sun, S. F., Hsu, C. W., Lin, H. S., Liou, I. H., Chen, Y. H., & Hung, C. L. (2017). Comparison of Single Intra-Articular Injection of Novel Hyaluronan (HYA-JOINT Plus) with Synvisc-One for Knee Osteoarthritis: A Randomized, Controlled, Double-Blind Trial of Efficacy and Safety. JBJS, 99(6), 462-471.
17. Lieberman, J. R., Engstrom, S. M., Solovyova, O., Au, C., & Grady, J. J. (2015). Is intra-articular hyaluronic acid effective in treating osteoarthritis of the hip joint?. The Journal of arthroplasty, 30(3), 507-511.
18. Zhang, H., Zhang, K., Zhang, X., Zhu, Z., Yan, S., Sun, T., ... & Zhang, J. (2015). Comparison of two hyaluronic acid formulations for safety and efficacy (CHASE) study in knee osteoarthritis: a multicenter, randomized, double-blind, 26-week non-inferiority trial comparing Durolane to Artz. Arthritis research & therapy, 17(1), 51.
19. Leite, V. F., Amadera, J. E. D., & Buehler, A. M. (2017). Viscosupplementation for hip osteoarthritis: a systematic review and meta-analysis of the efficacy for pain, disability and adverse events. Archives of physical medicine and rehabilitation.