Micronutrient therapy
| Abstract |
| Arthritis (from the Greek word "arthron", joint), is an acute or chronic inflammation of the joints and a disease of the so-called rheumatic conditions. The disease is characterized by stiffness, pain, joint deformity and limited mobility, as well as redness, swelling and pain (1)(2). More than 100 different types of arthritis exist in the literature, which differ in cause, course, and number of joints affected (3). Causes include chronic autoimmune processes (rheumatoid arthritis, ankylosing spondylitis, psioriatic arthritis), metabolic diseases with pro-inflammatory crystal deposits (gout, chondrocalcinosis), and acute infections (bacterial/septic arthritis, lyme arthritis) (4)(5)(6). An exception to this is activated osteoarthritis, a form of osteoarthritis with acute inflammation, which is also associated with swelling, redness, increased pain and hyperthermia (7). Depending on how many joints are affected, it is referred to as monoarthritis (one joint affected), oligoarthritis (two to four joints affected), or polyarthritis (five or more joints affected) (8). Diagnosis is made after history and physical examination with additional laboratory tests and imaging techniques, and subsequent therapy adapted according to the form of arthritis (9)(10)(11). Arthritis should not be confused with arthralgia, which is also a joint pain but without inflammation (12). Also to be distinguished in this context is the degenerative disease osteoarthritis, which is associated with cartilage degradation and bone damage (13). |
| Causes |
| Depending on the type of disease, various factors may be the cause of arthritis. Rheumatoid arthritis is an autoimmune disease triggered by a dysfunction of the immune system. According to the current state of knowledge, the etiology of rheumatoid arthritis, like that of many other autoimmune diseases, is due to an interaction of genetic factors (especially the presence of the HLA-DRBI variant), unhealthy lifestyle (smoking, poor diet), and environmental factors (air pollution, viral and bacterial infections) (14). Metabolic diseases with pro-inflammatory crystal deposits, such as gout, lead to uric acid deposition in the joints due to prolonged hyperuricemia, which in turn can induce joint inflammation. The causes of gout vary and can be either congenital, or acquired. The congenital cause is due to elevated uric acid levels in the blood or inadequate excretion. Acquired causes sometimes include diseases such as cancer and anemia, the use of certain medications (including diuretics), cancer therapies, and an unhealthy lifestyle (6)(15). In bacterial arthritis, or septic arthritis, caused by acute infections, bacteria (mainly Staphylococcus aureus and Streptococcus), viruses (mumps, rubella, hepatitis B, hepatitis C, HIV viruses or parvovirus B-19) or fungi are responsible for the inflammation. As a result, after only a few hours or days, a so-called joint effusion often develops due to fluid accumulation, which usually affects the knee, the hip joints or other joints (16). The germs usually enter the joint from the surrounding tissue (e.g. osteomyelitis) or from a source of infection in the body via the bloodstream, and less frequently via injuries or medical interventions (17). |
| Symptoms |
| Depending on the type of arthritis, the symptoms associated with the disease also differ. In rheumatoid arthritis, also known as chronic polyarthritis, there is a chronic, episodic inflammatory process of the synovium (synovitis) and subsequent degradation of cartilage, bone and ligaments. The abnormal production of inflammatory mediators such as interleukins 1, 6, and 8 and tumor necrosis-alpha ultimately leads to destruction of joint structures, but internal organs may also be affected (18). Rheumatoid arthritis manifests as polyarthritis of the finger and toe joints, morning stiffness, and swelling of the joints, but in some affected individuals also tendovaginitis, so-called rheumatoid nodules, and nonspecific symptoms such as mild fever, night sweats, and sleep disturbances. The disease can also manifest in organs such as the lungs, heart, and eyes (19). In the affluent disease gout, crystallization of monosodium urate salts occurs under acidic conditions, particularly in the joints, due to elevated uric acid levels (hyperuricemia). Destabilization of these deposited uric acid crystals results in an inflammatory reaction and consequently an acute and predominantly nighttime gout attack, usually affecting the metatarsophalangeal joint. Symptoms of a gout attack include severe pain, swelling, joint hyperthermia, redness, and tenderness to touch (6)(20). In contrast, in chondrocalcinosis (pseudogout), the inorganic pyrophosphate from the chondrocytes combines with calcium to form calcium pyrophosphate crystals, which are deposited in the joint spaces and lead to acute joint inflammation (predominantly knee and wrist) and tissue damage with associated pain. Either acute episodes of joint inflammation may occur, or chronic arthritis may develop, the symptoms of which are more similar to rheumatoid arthritis (stiffness of the joints). Metabolic disorders such as hyperparathyroidism may increase the incidence of calcium pyrophosphate deposition (21)(22). Septic arthritis results as an inflammatory response to direct or indirect contamination, because the invasion of bacteria into the synovial fluid and the additional release of their toxins induce the release of inflammatory mediators. Here, rapid action is essential, as sepsis may be imminent without punctation, intravenous antibiotic administration, and surgical intervention if necessary. The resulting joint effusion is accompanied by redness, swelling, hyperthermia, severe joint pain and possibly fever (10)(16). |
| Diagnostics |
| In the diagnosis of arthritis, physical examination plays an essential role in differentiating between articular and nonarticular joint pain in patients with musculoskeletal complaints, in addition to the medical history taken by the physician. For example, nonarticular pain may occur as a result of fibromyalgia, where patients are tender to pain but there is no swelling, effusion, or warmth (23). Other diseases such as tendinitis also manifest periarticular pain due to the inflammation of the tendon sheath that occurs, but the clinical picture is different from that of arthritis (24). For this reason, systematic assessment of the joints is essential if the patient reports swelling, tenderness to touch, severe pain, redness, joint stiffness, deformity, weakness, and instability in the history. In this context, however, it should be mentioned that these symptoms are more pronounced in acute inflammation, such as in bacterial arthritis, than in chronic arthritis, such as rheumatoid arthritis (9)(17). In particular, pain worsens in many patients during activities throughout the day. Inflammatory forms of arthritis also causes morning and rest pain, which may initially improve with activity but can certainly worsen with prolonged exertion. In addition, morning stiffness lasting longer than 45 minutes is also associated with inflammatory arthritis, although it is also associated in patients with osteoarthritis or fibromyalgia (25)(26). In rheumatoid arthritis, the 2010 ACR/EULAR classification criteria of the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR), as well as the collection of various laboratory parameters (nonspecific such as C-reactive protein (CRP) and erythrocyte sedimentation rate as inflammatory parameters and specific such as rheumatoid factor (RF) and CCP antibodies) and are used to establish the diagnosis, in addition to the physical examination. In addition, imaging techniques such as sonography, radiography, and MRI can also be used to detect inflammation or changes in bone (27)(9). The diagnosis of gout is based on physical examination in addition to history and, in the case of an acute gout attack, also on gel puncture followed by analysis of the synovial fluid and a blood test. In addition, as in rheumatoid arthritis, imaging techniques may help in establishing the diagnosis, and analysis of serum uric acid levels may also be used (11)(28). Similarly, in the diagnosis of pseudogout, synovial fluid examination, as well as sonographic techniques and radiography, are used (22). In septic arthritis, in addition to the physical examination mentioned initially, the diagnosis is still based on laboratory examination of specific inflammatory parameters (CRP and ESR) x-ray and punctation (10). |
| Treatment |
| In the treatment of any form of arthritis, the primary focus is on reducing pain, containing inflammation, and improving the function of the joint. Nonpharmacologic therapy may include, but is not limited to, targeted exercise, physical and occupational therapy, the use of orthopedic devices (e.g., orthotics), heat and cold treatments, and traditional Chinese medicine, e.g., in the form of acupuncture (29)(30). Pharmacological therapy involves the use of various drugs depending on the form of arthritis, including topical nonsterodial antirheumatic drugs (NSAIDs), topical capsaicin and duloxetine, corticosteroids. If neither non-pharmacologic therapy nor pharmacolgic therapy are unsuccessful, surgical intervention of the affected joint can be performed if necessary (14)(11)(18). In chronic autoimmune processes such as rheumatoid arthritis, due to the fact that it is an autoimmune disease that cannot be cured according to the current status, the focus is on lifelong pharmacologic therapy with anti-inflammatory and analgesic anti-rheumatic drugs with an emphasis on early remission of the disease and prevention of radiographic progression (31). In metabolic diseases with proinflammatory crystal deposits such as gout (arthritis urica), which is predominantly characterized by painful episodes of disease, anti-inflammatory drugs are the number one choice in treatment (32). In addition, nutritional therapy also plays an essential role in this case, as diet can also have a direct effect on uric acid levels (33). In arthritides with acute infections as the cause, as in septic (infectious) arthritis, therapy primarily involves the administration of analgesic and anti-inflammatory drugs. In bacterial arthritis, intravenous antibiotics are the treatment of choice, as is drainage of the synovial fluid in the course of arthroscopy(17)(34). |
| Diet for Arthritis |
| Since arthritis is a chronic inflammatory condition, nutritional approaches are based primarily on the beneficial effects of foods with anti-inflammatory properties. In this context, special mention should be made of the Mediterranean diet, which is characterized by a high proportion of unsaturated fatty acids such as olive oil, a low consumption of meat (especially red meat), a moderate consumption of yogurt and cheese, as well as abundant regional and seasonal fruits and vegetables, legumes, nuts, and predominantly whole grains (35). Particularly noteworthy is the high content of omega-3 fatty acids (in fatty cold-water fish such as salmon, mackerel, and tuna, but also in microalgae such as Ulkenia or the Schizochytrium alga and vegetable oils such as linseed, nut, and rapeseed oil), whose anti-inflammatory effects have been demonstrated in a large number of clinical studies and may also have a positive effect on the number of swollen and painful joints and consequently on disease activity in arthritis (36). Nutritional therapy in gout is considered an essential component of treatment, as it can reduce uric acid concentrations even without drug intervention. According to the Austrian Society for Rheumatology and Rehabilitation (ÖGR), evidence-based lifestyle recommendations for gout included a diet low in purines (found in pork, beef, and lamb, among others), fructose (certain fruits and vegetables and their juices), and alcohol (especially beer and spirits)(37). |
| Relevant micronutrients |
| Promotes the formation of synovial fluid |
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Glucosamine sulphate, chondroitin sulphate and hyaluronic acid are classics of nutritive concomitant therapy of athrosis. As natural building blocks of joints, they promote the formation of synovial fluid. Their ability to bind water ensures elasticity and suppleness of the cartilage, optimum viscosity of the synovial fluid and thus a better buffer function, which reduces pain. In addition, the substances contained in the synovial fluid serve as a substrate for the chondrocytes, which must be regenerated regularly. |
| Supplies antioxidants |
| In patients with osteoarthritis systemic and locally increased oxidative stress is observed. Reactive oxygen species (ROS), which develop as a result of abnormal chondrocyte metabolism, lead to increase in oxidative stress. The increased of ROS can accelerate the destruction of tissue structures and promote inflammation. The intake of antioxidants, integral trace elements (copper, manganese, selenium) and antioxidative enzymes can reduce further oxidative damage and have a positive effect on inflammatory processes.
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| Reduces inflammation and pain |
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Frankincens extrakt (Boswellia serrata) contains boswellic acids, triterpene acids and terpene alcohols and is particularly suitable for the treatment of acute and chronic pain caused by inflammatory processes in joints, muscles and the spinal column. |