Can we find different approaches to conventional anti-inflammatory medicines for arthritic pain and disability? The best prospects may be from looking at underlying causes and processes that are amenable to herbal action.
Arthritis means ‘inflammation of the joints’ and is an umbrella term for many different conditions marked by joint pain and damage. Joints are engineering miracles but still tend to wear through life and are increasingly likely to be troublesome as the years roll by: this is not a modern problem, nor confined to humans. Optimum joint health seems to average around 50 years: longer life span is a challenge. Weight and stress are the main burdens, and keeping joints mobile is generally a good thing: swimming may be the ideal exercise. ‘Wear and tear’ is associated with the most common type of arthritis, osteoarthritis. This is however an active disease of the joints as well, associated with local inflammatory activities involving the microcirculation and even insulin resistance.
Oher types of arthritis have wider more systemic inflammatory, usually immunological causes. They include rheumatoid arthritis, ankylosing spondylitis, Sjögren’s syndrome, polymyalgia rheumatica, lupus erythematosus, Reiter’s syndrome and psoriatic arthropathy. Not all blood or antibody tests are clear and some individual joint problems are described as ‘rheumatoid like’. All should be approached as a body-wide immunological and chronic inflammatory problems, rather than just a joint condition.
How does arthritis work?
Joints may be harmed by uric acid deposits, following build up of this metabolite in the blood. This can lead to an extremely painful arthritis called gout.
Joints are lined by a tough tissue called cartilage, designed to survive interrupted blood flow and pressure. Early arthritic inflammation, whether local or systemic, initially has transient effects, that might include swelling and pain in the surrounding tissues and perhaps in cushioning fluid-filled sacs called bursae. If persistent, this could then lead to provocation of the cells that produce cartilage, (chondrocytes), with subsequent spillover to affect the nearby bone-producing cells, (osteocytes). This is when inflammation leads to joint damage. The first aim of treatment for arthritis is to prevent this by catching the inflammatory changes early.
There is another category of joint and muscle pain in which an inflammatory backdrop is exacerbated by heightened responses throughout the system. Fibromyalgia is a syndrome marked by widespread musculoskeletal pain and symptoms such as fatigue, upset sleep, digestive problems and psychological distress. It is diagnosed on the basis of multiple tender points on the body and high pain scale scores. Investigative findings include exaggerated pain and sensory processing in the central nervous system, possibly linked with disturbances in neurochemical transmission (such as raised levels of substance P which is a neurotransmitter involved with pain), and with changes in hypothalamic control of hormone systems in the body. Because of the particular nature of this syndrome it may be more effective to manage it herbally not as a joint disease at all, but as evidence of a wider disruption in hormonal and other internal controls, requiring various calming tonic and adaptogenic herbs, as well as a wider convalescent regimen.
Signs and symptoms
Symptoms vary across different kinds of arthritis but general symptoms include:
- Joint pain
- Joint swelling
- Decreased mobility
- Difficulty walking and climbing stairs particularly if arthritis is in the knees or hips
- Morning stiffness is associated with osteoarthritis
- Warmth/ heat
- For some people with rheumatoid arthritis firm swellings called rheumatoid nodules can develop under the skin around affected joints
- People with rheumatoid arthritis can also experience fatigue, weight loss, a loss of appetite, sweating and a high temperature
- People with osteoarthritis can experience a crackling sound in the joints, and joints appearing larger than normal
Herbal and holistic solutions
The traditional view of joint diseases was that they represented toxic accumulation. Intuitively joints were understood as ‘bottlenecks’ in the circulation: if toxic matter was to get stuck anywhere it was likely to be the joints. Therefore, around the world approaches to arthritis were focused on cleaning up toxins around the joints.
This may sound quaint but there was no room for speculation here. Arthritis could cripple and threaten lives and livelihoods. Treatments needed to work urgently and only those that did so were recommended. There are stories of country herbalists in the 19th century setting up shop in the new towns of the British industrial revolution not getting their payments until their working patients’ joints were eased.
This urgency and need for results led to great popularity of the most direct treatment of all.
External treatments: counter-irritation
If arthritis represents a local toxic accumulation, then direct local measures are the obvious treatment. Applying heat was the simplest effective approach to reducing pain. We now understand this as increasing circulation into the joint, bringing more blood, more defensive white blood cells, and improving cleansing of the joint tissues. More fundamentally heating substitutes for the process of inflammation itself. The body’s inflammatory response is a defensive and healing mechanism, invoked when normal tissue cleansing and repair are compromised. Inflammation involves a major increase in heat (reddening) and circulation (swelling) that brings a major influx of white blood cells for some intensive cleaning up. Unfortunately, inflammation is accompanied by the production of pain-causing chemicals like histamine (that reminds us we need to rest and protect the inflamed tissue). Simply heating the tissue provides much of the benefits of inflammation without the disabling pain.
A hot water bottle, heating liniment from the pharmacist or products like Tiger Balm are popular applications of this principle. The relief from pain is not an illusion and if repeated regularly can lead to long-term gains. If there is no immediate benefit, or even a worsening of symptoms do not persevere with this tack: some cases of inflammatory arthritis or gout can be stirred by heat.
If heat is helpful however something stronger may be needed to make sustained progress. Hot poultices or baths with mustard, pepper or cayenne are the next step up. There is strong evidence that cayenne or chillies, containing capsaicin, can directly reduce arthritic inflammation and additionally act on the pain sensors. There are similar pointers for ginger.
Mustard is justifiably perhaps the most popular of all. A simple home remedy is yellow English mustard powder applied as a paste on a warm pad, as a mustard plaster, or as mustard bath for fingers and toes (in this case put the mustard in a small bowl of hot water, but put this inside a larger basin of hot water to maintain its temperature). Fifteen minutes of a mustard application can often lead to significant quick relief. If repeated it can build up a longer-term effect. One can also buy cayenne or capsaicin plasters or use ginger in a similar way. The skin underneath these applications will often get quite red; when sensitive there is a slight risk of blistering so one needs to check frequently. However, it is worth noting that this ‘problem’ was also traditionally the most powerful solution.
Blistering was a common technique for immediate relief of arthritis. It was seen as an extreme ‘heating’ technique, so strong that the toxins could be drained off directly by lancing the blisters! At its simplest, ﬂaying the joint with stinging nettles has been a popular folk remedy, earlier used by the Romans, but more corrosive substances like croton oil and formic acid (found in ant bites and stinging nettle) became favoured as they were industrially isolated. For the 19th century British industrial working classes without social security support, arthritis could threaten their livelihoods. Blistering could allow them to get back to work. Professionally applied the application could generate an impressive quantity of ﬂuid. However this is a risky intervention and there are good reasons why it is not generally available and we do not recommend it.
Internal treatments: Clearing acid wastes
As seen above a consistent theme in traditional approaches to arthritis was to remove toxic accumulations from the affected joints. A common focus was on the kidneys, with the implication that joints suffered when they were below par or overwhelmed. Whatever the explanation many traditional treatments for arthritis were also diuretic remedies, perceived as helping the body remove toxic waste through the urine. In European medicine herbs such as celery seed, birch, and dandelion root were widely used diuretics in the treatment of arthritic disease.
A major role for the kidneys is to maintain acid and alkaline balance in the body. Indeed all body’s eliminations clear acid metabolites, the bowel, sweat and notably the lungs (carbon dioxide is an acidic waste product). Normal tissue metabolism involves the generation of acidic breakdown products and so the body expends much effort getting these out. The kidney is the arbiter of how well this clear out is being done and has the ability to get more out by acidifying the urine if necessary.
In European and post-settler North American traditions arthritis was seen as associated with an excess acid in the body. To reduce this burden the European naturopathic tradition advises eating more alkali-generating foods and cutting back on those that produce more acids. Confusingly this has little to do with how the food tastes. Fruit, vegetables and most plant-based foods generate more alkalis; protein foods especially from animal products generate acids. To clarify this, it is simplest to compare digestion with combustion: they yield the same mineral residues. If you burn a lemon the ash is alkaline; if a steak the ash is acidic. There is a more sophisticated measure called PRAL (potential renal acid loads) that takes account of different nutrient absorption rates, Highest PRAL foods include cheese, processed meats, and egg yolks; lowest PRAL foods are some vegetables and fruits. Proteins generate acidic sulfur residues; plants tend to be richer in potassium, sodium and calcium (although a few also produce persistent acid residues such as oxalic and tartaric acids). The general conclusion is that plant-based diets are a good foundation for managing arthritic conditions.
A classic example of the acidic waste thesis is gout, an arthritis provoked by accumulation of uric acid crystals in the joint. Uric acid is one of the normal range of acidic metabolites (in this case from urea) but this can be excessive in some people. The diuretic herbs listed above are particularly helpful in this condition. It is also wise to reduce consumption of uric acid producing foods such as liver, kidney, excessive red meat, sardines, mackerel and anchovies.
As well as approaches that help the kidney there are herbs traditionally used to reduce joint pain that appear to reduce inflammatory activity itself. These include turmeric, ginger, boswellia, rosehip, willow bark (probably best avoided in gout) and devil’s claw, as well as some plant oils, from flax or linseed, evening primrose and blackcurrant.
Internal treatments: Addressing immunological factors
Apart from wear and tear, the most frequent problems for joints involve disturbances of inﬂammatory and immunological mechanisms. One leads to the other: chronic inflammatory conditions often engage complex immunological disturbances which then exacerbate the original provocation and lead to secondary tissue damage. ‘Auto-immunity’ is the term used to describe immunological disease brought about by internal antigens. It is a common feature of inflammatory arthritic problems.
The conventional approach to inﬂammatory and immunological problems is to suppress the manifestations with anti-inﬂammatory drugs, either steroids or the non-steroidal anti-inﬂammatories (NSAIDs), Although these can be dramatically effective, they are associated with sometimes serious side effects.
Traditional herbal practice has a very different approach, firstly to see and support inflammation as a healthy defensive mechanism, and then to ease any pressures that may provoke it to dangerous complications. Keeping the defences healthily separate from the ‘last resort’ antibody-producing immune system is one important priority. There are several scientific insights that can reinforce ancient practices here.
Maintaining endothelial health: Chronic low-grade systemic inﬂammation is marked by increase in C-reactive protein (CRP) and other inflammatory cytokines, such as TNF-alpha, and the interleukins. These often start being generated in the vicinity of the affected tissue at the surface of the blood vessels (endothelium). The result is an increase in a range of defensive activities, notably the migration into the tissues through the blood vessel walls of activated white blood cells, dilation of the blood vessels, and changes in clotting behaviour. These healthy inflammatory defences can deteriorate into chronic inflammatory disease like rheumatoid arthritis if the endothelial mechanisms are disrupted: a situation sometimes described as endothelial dysfunction. Many simple plant foods are likely to support endothelial integrity: fruits and vegetables with high polyphenol content (that often colour the food, so red and purple foods are notable), cocoa, and notably the spices like turmeric, ginger, cinnamon and cayenne all hold promise as stemming inflammatory pressures upstream.
Clearing old infections: There is also increasing evidence that many inflammatory diseases like rheumatoid arthritis and ankylosing spondylitis start with a primary infection and are caused by the body’s immune system confusing the pathogen with the affected tissue (‘molecular mimicry’). Any longstanding, even low-level infection, especially in the gut, gums, lungs, and urinary system, can generate ‘immunological cross-reactivity’ and power a complex autoimmune condition. This could be an old lung infection (even back in childhood), chronic urinary or prostatic infections, dysbiosis in the gut or low-level infections like Helicobacter pylori. Potentially the most damaging immune-activating agents are viruses and other ‘stealth pathogens’, marked by flying under the radar of detection and antibiotic treatments. An example is the link between Epstein–Barr virus (‘glandular fever’) and rheumatoid arthritis.
A classic illustration of the infectious connection is that rheumatoid arthritis appears to have been unknown in Europe until the 17th century, after the discovery and colonisation of North America. By contrast the bone record shows native North Americans have always had relatively high levels of the disease going back several thousand years. Given the lack of genetic exchange it seems more likely that it was an infectious factor that brought the disease into Europe.
Traditional herbal practitioners have long tackled complex inflammatory diseases by hunting for ‘toxic’ focal points, signs of prior infections and tissue damage, and have formulated their prescriptions to deal with these, rather than at the symptoms. This is a policy still to be recommended to herbal practitioners.
Healing the gut wall: A strong suspect in the generation of unhealthy immunological responses is a breach in the intestinal wall. There is considerable evidence pointing to such damage in inflammatory joint diseases, often without signs of digestive problems. This may involve intrusion of gut pathogens like activated E.coli, or simply the crossing over of a higher antigen load from the digestive tract. The links between gut and joint inflammations has got as far that some authorities consider them aspects of the same disease. Reducing this damage by removing provocative food intolerances, improving bile quality (the ‘wrong sort’ of bile can be a potent cause of intestinal wall damage), reducing sulfide generating animal proteins, and focusing on healthy prebiotic, probiotic and gut nurturing foods, can sometimes lead to dramatic benefits in inflammatory joint problems.
Again common spices may help on a number of fronts: turmeric for example has demonstrable effects in healing the gut wall, ‘sweetening’ the bile, and is even an effective prebiotic. (It is these benefits, rather than direct effects on the joints of a very poorly absorbed curcumin, that are the most likely way in which turmeric helps arthritis). Ginger may have similar benefits.