Treatment of Joint Pain


We are going to deviate from the mechanical discussions of joint pain treatment. Usual topics such as physiotherapy, stretching, manipulation, etc… and instead we’re going to discuss what looks to be a remarkably inexpensive yet potentially valuable tool in combating joint pain and inflammation.


Far removed from today’s ultra-popular yet often little tested “health foods” and “supplements” this tool has undergone testing and research typically avoided by “natural substances” and we’ll be discussing those studies in just a little bit.


The tool I’m referring to is the “Omega-3 Essential Fatty Acids”


Fatty acids are a chain (of variable length) of carbon atoms that have a starting carboxyl group (-COOH). The ending carbon of the chain is known as the omega carbon. The ending omega carbon is also a methyl group, meaning it is bonded with three hydrogen atoms (-CH3).


There are four broad categories of fatty acids***:


(see the appendix of this issue for a detailed chemistry primer of fatty acids and their components)


Saturated


Monounsaturated


Omega-3 polyunsaturated


Omega-6 polyunsaturated


Essential For Human Health


Importantly, both omega-6 and omega-3 fatty acids are essential for human health, and our patient’s bodies do not have the ability to create them from other fatty acids.


Consequently, both omega-6 and omega-3 fatty acids must be consumed in the diet. Dietary deficiencies in either omega-6 or omega-3 fatty acids are deleterious to our patients health.


Additionally, the ratio of omega-6 to omega-3 fatty acids is critically important. “Historical estimates place the ratio of omega-6 to omega-3 oils at nearly 1:1 for prehistoric humans.”


The ratio of omega-6 to omega-3 fatty acids has changed dramatically due to the widespread use of vegetable oils (mostly n-6 fats) in cooking and foods.


By 1900, the ratio of omega-6 to omega-3 fatty acids had increased to about 4:1.


The current American ratio is about 25:1.


This “sharp rise is due to increased vegetable oil consumption: from 2 lb. per year in 1909 to 25 lb. per year in 1985!” (Mark Boswell and B. Eliot Cole, editors;American Academy of Pain Management Weiner’s Pain Management, A Practical Guide for Clinicians; Seventh Edition, 2006, pp.584-585.)


*(For the biological enzymatic processing of omega-6 fatty acids schematic see the appendix at the end of this issue)


A critically important aspect of essential fatty acid biology is…


The 20-carbon long omega-6 and omega-3 fatty acids are the precursors to a group of powerful but short-lived hormone-like compounds called “eicosanoids.”


One category of eicosanoids is referred to as “prostaglandins.”


Another group is referred to as “leukotrienes.”


Clinical applications of this biochemistry includes:


Arachidonic Acid (AA), the 20-carbon long omega-6 fatty acid is enzymatically converted into the eicosanoids called “series 2 prostaglandins,” such as “Prostaglandin E2 (PGE2),” by enzymes referred to as “cyclo-oxygenase” or “COX.”


Prostaglandin E2 is pro-inflammatory, which alters the threshold of the pain afferent neurons in the region, and patients experience increased pain.


Arachidonic Acid (AA), is also enzymatically converted into the eicosanoids called “series 4 leukotrienes,” such as “Leukotriene B4 (LTB4),” by enzymes referred to as “lipo-oxygenase” or “LOX.”


Leukotriene B4 is also pro-inflammatory, and patients experience increased pain.


Eicosapentaenoic acid (EPA), the 20-carbon long omega-3 fatty acid is enzymatically converted into the eicosanoids called “series 3 prostaglandins,” such as “Prostaglandin E3 (PGE3),” by the same cyclo-oxygenase (COX) enzymes that convert arachidonic acid into pro-inflammatory prostaglandin E2.




Historically, the conversion of arachidonic acid into pro-inflammatory prostaglandin E2 has been inhibited by utilization of nonsteroidal anti-inflammatory drugs (NSAIDs) that block the cyclo-oxygenase (COX) enzymes.


However, as noted in the article reviews below, long-term use of these drugs can cause problems in some patients.


Additionally, the article reviews below indicate that nonsteroidal anti-inflammatory drugs (NSAIDs) do not inhibit the lipo-oxygenase (LOX) pathway and therefore do not inhibit the formation of pro-inflammatory series 4 leukotrienes.


In contrast the omega-3 fatty acid Eicosapentaenoic acid (EPA) inhibits both cyclo-oxygenase (COX) and lipo-oxygenase (LOX) enzymes, reducing the production of both pro-inflammatory prostaglandin E2 and series 4 leukotrienes.




Pain:


“Omega-3 Fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain”

Surgical Neurology 65 (April 2006) 326– 331 This paper won first prize in the poster competition at the American Association of Neurological Surgeons Annual Meeting, New Orleans, LA, April 2005


Joseph Charles Maroon, MD, Jeffrey W. Bost, PAC


These authors are from the


Department of Neurological Surgery, University of Pittsburgh Medical Center


FROM ABSTRACT:


Background:


The use of NSAID medications is a well-established effective therapy for both acute and chronic nonspecific neck and back pain.


Extreme complications, including gastric ulcers, bleeding, myocardial infarction, and even deaths, are associated with their use.


An alternative treatment with fewer side effects that also reduces the inflammatory response and thereby reduces pain is believed to be omega-3 EFAs found in fish oil.


We report our experience in a neurosurgical practice using fish oil supplements for pain relief.


Methods:


From March to June 2004, 250 patients who had been seen by a neurosurgeon and were found to have nonsurgical neck or back pain were asked to take a total of 1200 mg per day of omega-3 EFAs (eicosapentaenoic acid and decosahexaenoic acid) found in fish oil supplements.


Results:


78% were taking 1200 mg and 22% were taking 2400 mg of EFAs.


After an average of 75 days on fish oil:


59% discontinued to take their prescription NSAID medications for pain.


88% stated they were satisfied with their improvement and stated they would continue to take the fish oil.


There were no significant side effects reported.


Conclusions:


Our results mirror other controlled studies that compared ibuprofen and omega-3 EFAs demonstrating equivalent effects in reducing arthritic pain.


Omega-3 EFA fish oil supplements appear to be a safer alternative to NSAIDs for treatment of nonsurgical neck or back pain.


KEY POINTS FROM AUTHORS


Maroon & Bost from


Department of Neurological Surgery,


University of Pittsburgh Medical Center


1) The use of NSAIDs is associated with occasional extreme complications, including gastric ulcers, bleeding, myocardial infarction, stroke, and even death.


2) In this study, after 75 days on fish oil, 59% of patients who were taking NSAIDs for chronic spinal pain and who had degenerative spine disease, were able to discontinue their prescription NSAIDs, and 88% stated they were satisfied with their improvement and that they would continue to take the fish oil.


3) In this study, fish oil supplementation was not associated with any significant side effects.


4) “Omega-3 EFA fish oil supplements appear to be a safer alternative to NSAIDs for treatment of nonsurgical neck or back pain.”


5) “More than 70 million NSAID prescriptions are written each year, and 30 billion over-the-counter NSAID tablets are sold annually.”


6) “5% to 10% of the adult US population and approximately 14% of the elderly routinely use NSAIDs for pain control.”


7) Selling NSAIDs is a 9 billion dollar per year US industry.


8) Prescription NSAIDs for rheumatoid and osteoarthritis alone conservatively cause 16,500 deaths per year.


9) “NSAIDs are the most common cause of drug-related morbidity and mortality reported to the FDA and other regulatory agencies around the world.”


10) “The agent best documented by hundreds of references in the literature for its anti-inflammatory effects is omega-3 EFAs found in fish and in pharmaceutical-grade fish oil supplements.”


11) The beneficial anti-inflammatory affects of high-dose fish oil include the reduction of joint pain from rheumatoid and osteoarthritis, improvement in dry eyes and macular degeneration, reduced plaque formation, reduced arrhythmias, and reduced infarction from coronary arthrosclerosis.


12) COX-2 inhibitors significantly increase gastric and cardiovascular side effects.


13) Omega-3 EPA is used to make the anti-inflammatory eicosanoids (PGE3), whereas excess omega-6 EFAs form inflammatory arachidonic acid based eicosanoids (PGE2).


14) “Animal proteins, especially red meat, also contain an abundant amount of arachidonic acid.”


15) A deficiency in omega-3 fatty acids, especially EPA, will result in a deficiency of anti-inflammatory prostaglandins.


16) “To encourage the production of anti-inflammatory PGs and to discourage the production of inflammatory PGs, saturated fats, trans-fatty acids, and arachidonic acid should be reduced in the diet; blood glucose should be controlled; and appropriate amounts of omega-3 fatty acids found in fish oils should be consumed.”


17) Omega-3 supplementation is safe and effective for many inflammation-related conditions and has a low incidence of side effects.


18) “The US Department of Agriculture has limited fish consumption to 1 fish serving per week in adults and even less in children and