Osteoarthritis and Calcified Joint Tissues

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

Osteoarthritis is a nonspecific term for degenerative joint disease. Since so many cases of early stage or mild osteoarthritic degenerative joint disease are not diagnosed as such, or patients do not seek treatment specific to this disorder, it is hard to reliably set a rate of prevalence in the society. The National Institute of Arthritis and Musculoskeletal and Skin Diseases, part of the National Institutes of Health, does estimate that over 20 million United States citizens, or about 1 in 13 individuals, are diagnosed with osteoarthritis, making this the most common type of arthritis. The prevalence of osteoarthritis is significantly higher in women than men, suggesting some hormonal connection to pathology, and the progression of the disease in women during postmenopausal states is dramatic. Hormonal imbalance premenopausally may be a significant factor in the early progression of osteoarthritic changes.

Defining osteoarthritis precisely presents some difficulties. Although the term Osteo- means bone, the prefix Osteo- actually refers not only to bone pathology, as in outgrowths of the bone, or osteophytes, but also to calcifications of the joint tissues surrounding the bone. Osteoarthritis most often involves dysfunction related to the ossification of the cartilage, or bone covering at the joint, which normally ossifies, or turns into new bone, but in many degenerative joints stops replacing itself, leaving the bone at the joint unprotected from mechanical wear and tear. The process of ossification of cartilage is still not completely understood, although recent advances in scientific understanding are allowing us to improve our understanding of how to reverse cartilage degeneration and osteoarthritic degenerative joint disease (see the article on this website entitled Joint Degeneration and Arthritis).

While the classic public notion of osteoarthritis involves an advanced disease manifesting in patients with gnarled hands and fingers, and severely kyphotic spinal posture, the truth that most osteoarthritis occurs in less dramatic form. While the classic osteoarthritic hands of an elderly worker who has used the hands excessively, is a classic image, other weight bearing joints are more commonly the site of oesteorthritic degeneration in the general population. The cervical and lumbar spines are perhaps the most prevalent example of weight bearing joints suffering this type of degeneration, but the knees and hips are also very common locations, and thus knee and hip artifical joint replacements are now common. The key to proper health management of osteoarthritis is to identify it early in its course and start treatment at this stage. While is would seem to many that simply decreasing mechanical stress would perhaps solve the problem, studies have shown that activities such as running do not increase the risk of developing osteoarthritis, and in fact, for most patients slow the progress. Most experts now agree that such factors as mechanical misalignment of bones in the joints, imbalance of stabilizing and supporting muscle tensions, loss of muscle strength in supporting and active muscles of the joint, impaired circulation of blood and nerve conduction, and poor postural mechanical habits, are the key aspects that contribute most to this disease mechanism.

Osteoarthritis is a degenerative disease that must be slowed and reversed with a comprehensive protocol of conservative care. Treating just the symptoms will guarantee failure in stopping the progression of slow degeneration, and the best symptom relief will come from restoration of healthy joint tissues and function. Standard medicine has very little to offer in the treatment of osteoarthritis, and integrating Complementary Medicine, in the form of acupuncture, physiotherapies, herbal and nutrient medicine into your treatment protocol, along with an improved understanding of the mechanisms of the disease and a workable routine of self-administered therapies and correction of postural mechanics, is the formula for success. Difficult diseases require more work and the sensible patients are realizing this fact and taking a proactive approach.

In February of 2012, Duke University Medical Center released the findings of extensive long-term research, headed by Dr. Virginia Kraus M.D. Ph.D., and professor of rheumatology and immunology at Duke University Medical School. Dr. Kraus was surprised to find that the knee joint has a "capacity for repair we didn't know about, and the main treatment strategy probably would need to focus on turning off the breakdown of knee tissue." Of course, standard medicine is still looking for a purely pharmacological means of turning off the cellular processes of degeneration, but much research today points to the success of a more holistic approach. By eliminating the mechanical stresses, supplying the tissues with circulation and nutrients, stimulating immunohormonal tissue repair and maintenance, and encouraging the natural homeostatic mechanisms of tissue regeneration, the osteoarthritic degenerated knee will regrow healthy joint tissues.

The key to reversing osteoarthritic degenerative arthritis is the attention of a multifactorial cause. Mechanical, metabolic, developmental, and hereditary causes play potential roles in this degeneration. Mechanical and metabolic causes are most important, though, and hormonal regulation of metabolic needs of the bone and cartilage, as well as regulation of the complex calcium metabolism are very important in the homeostasis of joint maintenance. The joints degenerate in osteoathritis mainly due to degeneration of cartilage. When bony surfaces at the joint are not protected by new healthy cartilage, which turns into new bone at the joint continuously, the bone that is subjected to mechanical wear and tear, and is subjected to dystrophy, or lack of metabolic nutrients, becomes damaged and inflamed. This bone then grows bony protrusions, called osteophytes, and developes rough surfaces and excess growth, or hypertrophy, as well as a hardened surface at the cartilage bone junction, called eburnation, further obstructing the normal conversion of the basement layer of cartilage to new bone.

Inside this osteoarthritic bone, abnormal blood vessel formations, called hemangiomas, may also develop, and a number of peripheral vascular problems are now associated with osteoarthritic spinal arthroses. The joint becomes less mobile, and painful to move. With less movement, supporting ligaments become lax, and stabilizing muscles become weak and atrophy. The patient naturally avoids too much movement at these joints, but this only accelerates the degeneration. Joint mobilization, especially passive mobilization where a trained physician performs joint mobilization in therapy while the patient lies passive, and not weight bearing stress, is applied to the joint, is very important to maintenance and restoration. In Traditional Chinese Medicine, this part of the therapy is called Tui na. Concurrent supply of metabolic factors, including nutrients, hormones and growth factors, is also very important to restoration. Decreasing excess inflammatory processes may also be integral to the whole package of care, and various herbal and nutrient combinations will play an effective role in this regard, without side effects.

The total package of care needed to treat and reverse osteoarthritic joint degeneration should integrate Complementary Medicine

Standard treatment of osteoarthritic joint degeneration involves pain medication, surgical clearing of unhealthy joint tissues, and strength training in physical therapy. The treatment is described as management of the condition, not restoration of healthy tissue and function. A meta-review of treatment guidelines for the management of hip and knee osteoarthritis by the University of Edinburgh Osteoarticular Research Group (Zhang, Moskowitz et al: Osteoarthritis and Cartilage; Sept 2007; Vol.15(9): 981-1000) found that only 23 of 1462 treatment guidelines met the requirements for evidence-based quality of data, with even many of these based on opinion alone. The summary stated that "critical appraisal shows that the overall quality of existing guidelines is sub-optimal". While acupuncture has been discouraged in these standard guidelines for lack of evidence-based study, this meta-review showed that standard therapeutic protocols lack such evidence as well. In 2011, the American Academy (Association) of Orthopaedic Surgeons issued guidelines for the treatment of osteoarthritic degeneration of the knee that "suggested" that needle lavage (aspiration and irrigation) not be used, recommended against performing arthroscopic surgery for debridement (removal of unhealthy tissues) or lavage, could not recommend injection of hyaluronic acid into the joint, considered arthroscopic surgery with partial removal of the unhealthy meniscus or loose body (bone or cartilage fragments) optional, could not recommend osteotomy (surgical resection) of the degenerated tibial tubercle, and had no positive recommendations for surgical correction. In other words, the recommendations by the surgeons themselves was that the patient engage in a proactive course of treatment that utilized conservative care to stop continuing degeneration, promote healthy tissue growth, and correct underlying causes and contributors to the osteoarthritic pathology.

An effective package of care in the treatment of osteoarthritis, not just the management, should combine correction of mechanical muscle tensions and strengths, with myofascial release and neuromuscular reeducation, along with passive joint mobilization, acupuncture and electroacupuncture stimulation, and the use of herbal and nutrient therapies to correct a variety of potential underlying metabolic problems. Topical herbal therapies have been proven very successful in studies, and bioidentical hormones are very useful to correct subclinical thyroid, parathyroid, and other endocrine imbalances. A focus on both the underlying causes or contributors, as well as the physiology of tissue repair at the joint, in other words a holistic approach, is necessary. Concentration on just one aspect of this holistic approach is what has made therapy unsuccessful in general. Restoration of homeostatic mechanisms may take care of the problem permanently, instead of having it recur and negatively progress with aging. Appropriate targeted strength training and stretch, correction of unhealthy body mechanics, and a complete package of care performed both by the patient and the physicians and therapists, is needed. This proactive approach by the patient is needed for a successful outcome, as much work is needed to reverse osteoarthritic changes. The American College of Rheumatology has long recommended patient education, self-management programs, range of motion exercise, and weight loss with correction of obesity when needed. The knowledgable Complementary Medicine physician, or skilled Licensed Acupuncturist, can take the time to deliver this complete package of care.

Perhaps the most fundamental aspect of the holistic treatment of osteoarthritis is the need for movement and exercise, and without this the treatment protocol may fail, no matter what the protocol chosen. This has long been the advice in standard medical clinical guides, yet the advice which has most often been overlooked, both by the patients and the physicians. A large cohort study completed in 2011, entitled the Osteoarthritis Initiative, headed by Dorothy D. Dunlop of the Feinberg School of Medicine, and published by the American College of Rheumatology in Arthritis and Rheumatism, studied 2,589 patients with osteoarthritic knees between the ages of 45 to 79. Because of the painful disability, the vast majority of these patients spent most of their time off their feet, sitting or lying, and most exhibited inadequate exercise routines and activities of daily living to provide adequate circulation to the degenerative joint tissues. The data from this 2 year study showed a consistent linear relationship between physical activity and functional performance of the knees, adjusted for all age types, as well as gender, race, and related health problems, such as obesity, depression, other disease, habits, and for the severity of symptoms.

Without movement and activity the joint tissues, which are not well vascularized, do not receive nutrient circulation. Of course, passive movement, or mobilization, helps dramatically, as well as non-weight bearing movement and exercise, and a combination of therapeutic measures that decrease pain and provide helpful instruction and guidance for therapeutic activities and postural mechanics helps to motivate the patient to perform daily targeted exercise and mobilization. The study found that exercise involving repetitive knee flexion, especially squats, were detrimental to cartilage repair, but that frequent low-impact exercise definitely improved the joint health, and cartilage structure, with lowered T2 measurements in MRI studies, meaning that the water content of the cartilage, or swelling, was reduced, but that intact tissue architecture was increased. Daily low-impact exercise, especially without weight bearing, such as use of a stationary bike, or weighted movement exercise lying on the back, and inclusion of passive mobilization and exercise in therapy, is important in the overall protocol. When a professional helps the patient choose the most efficient daily routine, the rewards are improved dramatically, and the excercise and activity accomplishes the most with the least effort. By receiving comprehensive therapy in the form of acupuncture, electrical stimulation, soft tissue mobilization, myofascial release, and herbal and nutrient medicines, each patient is better able to cope with the demands for a daily exercise and therapeutic activity routine.

Modern research has explored many of the treatment modalities in Complementary Medicine, but has failed to assess the actual clinical practice of combining these various indivdual treatments into an individualized holistic package of care. As medical research continues to isolate one aspect of this needed holistic package of care in each study type, the benefits of just one treatment modality alone usually shows small or no benefit. The most benefits seen in these studies of isolated treatment protocols so far have been with acupuncture, electroacupouncture, and herbal/nutrient medicines. A new type of bioidentical collagen type 2, encapsulated in a patented method, developed over 15 years at Harvard Medical University, has shown modest benefit in osteoarthritis. No pharmaceutical drugs or surgical interventions have shown lasting positive effect. Many patients are now told to wait and take excessive pain medications until the joint really degenerates, and then get an artifical joint prosthesis due to the failure of each of these treatments alone to demonstrate efficacy in human clinical trials. Unfortunately, this pain medication dependency is very costly and comes with alarming adverse effects (see the article on this website entitled Pain Medication: Warnings and Alternatives), and the artifical knee or hip prosthesis usually lasts only a small number of years with a cessation of pain and good mobility before once again, the artificial joint wears out and the surrounding tissue becomes severely degenerated. Subsequent replacements of joint replacements come with a degrading set of outcomes. The end result is a crippling in old age as these artifical joints wear out and can no longer be replaced. These artificial joints, or prostheses, also do not address the main locations of osteoarthritic problems, namely the cervical and lumbar spine. In like manner, the increased use of prosthetic supports for the osteoarthritic and degenerated lumbar spine, with screws and spacers implanted, overlooks the long term health of the spine. Conservative care, even with use of these prosthetics, is very important to prevent further degeneration of the spinal joints. Without addressing the underlying health problems and doing the work to restore healthy tissues, the patient is experiencing only a temporary respite from the more severe pain and disability.

Finally, accepted evidence that acupuncture needle stimulation is effective in the treatment protocol for osteoarthritis

The main reason for patients not utilizing a comprehensive treatment protocol for osteoarthritis appears to be discouragement from their medical doctors, and lack of real trust that it will work once the degeneration of the joint becomes more severe. In recent years, acupuncture by itself has proven to be effective, though, while a comprehensive package of care combining this effective treatment with direct soft tissue therapies, myofascial release, instruction in body mechanics and therapeutic activities, and proven herbal/nutrient medicines is assuredly more effective than acupuncture alone. One drawback to the evidence of effectiveness lies in the problems of designing placebo-controlled randomized human clinical trials for the manual therapies. Of course, finding a true placebo needling method that is blinded to both the administering physician and the patient is nearly impossible. While randomized placebo-controlled trials of acupuncture are problematic in design, a number of large, well-designed studies have proven efficacy of acupuncture in the treatment of osteoarthritis (re: Berman et al, 2004, St. George's University of London in conjunction with 4 hospitals and 570 patients in the study of treatment of osteoarthritis of the knee, concluded that acupuncture provided significant improvement in function and pain relief as an adjunct therapy compared to sham acupuncture at 8 weeks, and follow-up at 26 weeks. A follow-up study in 2005, sponsored by the National Institutes of Arthritis and Musculoskeletal and Skin Diseases, part of the NIH and U.S. Dept. of Health and Human Services, also showed a symptom decrease of 40% as judged by WOMAC scales, and concluded: "For the first time, a clinical trial with sufficient rigor, size, and duration hs shown that acupuncture reduces the pain and functional impairment of osteoarthritis of the knee." Dr. Stephen I. Straus, M.D. Director of the National Center for Complementary and Alternative Medicine.) Numerous studies also show significant benefits of acupuncture for relief of back pain in large, randomized clinical trials. Even the Cochrane Database, with a well-known bias against the acupuncture profession, admits in 2010 with metareview of published clinical trials of acupuncture of peripheral joint osteoarthritis that placebo-controlled clinical human trials show statistically significant benefits (PMID: 20091527). The proof of effectiveness is no longer in question. Real effectiveness, though, is seen with the adoption of acupuncture within a comprehensive treatment protocol.

The physiology of normal replacement of healthy bone and cartilage at the joint, an ongoing process that may need help

A number of important factors are now known about what makes the innermost layer of cartilage turn into new bone, and what makes the outermost layers form anew. The process of ossification of cartilage is largely controlled by an isomer, or type, of the hormone that we generally still call Vitamin D3, but whose real name is calcitriol. Calcitriol is made in the kidney, and depends upon a constant daily supply of a precursor hormone called calcidiol, which depends upon a precursor prohormone called cholecalciferol, which is derived from cholesterol that is stored in the skin and converted with exposure to sun radiation. This is a complicated process, and simple supplementation with a small dose of cholecalciferol, or what we call Vitamin D, is often not enough to correct deficiencies. The rate of turnover of all layers of cartilage appears dependent on the ossification of the basement layer, making this hormone Vitamin D3 perhaps the most important regulator of cartilage health. Studies in the United States in some areas have found greater than 80 percent of the aging population deficient in the hormone Vitamin D3 (see a separate article on this website explaining the misconceptions of so-called Vitamin D3 supplementation). A high dose liquid cholecalciferol supplement is recommended in this protocol to be effective, and active metabolite testing with veinous bloodstick is helpful to gauge the actual level of calcitriol D3 deficiency.

A couple of important chemicals have been discovered with a strong relationship to cartilage destruction and repair as well. Cartilage oligomeric matrix protein (COMP) is integral to cartilage repair. COMP is found in circulation, in tendon tissues, and in meniscus. Cells of the synovial membranes may be stimulated to increase COMP production by transforming growth factor beta (TGF-beta). COMP concentrations are much higher in synovial fluid of joints than in blood serum, suggesting that it is mainly produced locally in the joints. Excess of COMP is found in the synovial fluid of acutely injured joints, and hence the level of COMP in circulation is noted as a biomarker of osteoarthritis and degenerative cartilage diseases. As with all such chemicals in the body, a complex system of balance and regulation is the most important factor in restoring of homeostatic tissue repair mechanisms. A number of effectors of TGF-beta and COMP production are being researched, including acupuncture, physiotherapy (Tui na), herbal and nutrient medicines. To achieve success, though, a holistic approach to providing better homeostatic balance of a number of synergistic chemicals may be important, not just the allopathic blocking of one such chemical, such as D-COMP (a COMP epitope associated with hip, but not knee, osteoarthritis). Immune cytokines, antibodies, chemokines, and growth factors may all need to be expressed and circulated in a healthy system to restore cartilage growth. Markers of disease, such as elevated COMP, may indicate accumulation of protein fragments, fibrins, and deamidation, or protein breakdown without clearance, which may be affected by elevated pH and temperature in the tissue. Proteolytic enzymes such as serratiopeptidase and nattokinase are used to clear tissues of peptides (protein fragments) and fibrins.

Researchers in the United Kingdom have discovered a signature epigenetic change associated with osteoarthritis and cartilage degeneration as well. The destructive enzyme MMP3 (matrix metalloproteinase-3), a zinc-dependent protease, capable of speeding the degradation of collagens, may be epigenetically inhibited with DNA methylation. Osteoarthritic patients had less DNA methylation, increasing the levels of MMP3, suggesting an epigenetic change. In 2011, research at the Chinese Academy of Medical Sciences in Beijing, China (see study link below), found that acupuncture can down-regulate the expression of MMP-3 and MMP-1, and up-regulate the expression of TIMP-1 (tissue inhibitor of metalloproteinase-1), explaining in part the positive effects of electroacupuncture therapy on cartilage regrowth. The acupuncture points ST35 and ST36 were used in this study, and compared with the effects of Diclofenac (NSAID) cream, with better results than the pharmacological treatment. DNA methylation is a crucial biochemical process in cell differentiation, and some methylation processes are inherited or acquired, and referred to as epigenetic regulation. Researchers at the National Cancer Institute have found that deficiencies of dietary methyls (methionine, folate, and choline) may play a part in combination in hypomethylation. The use of zinc monomethionine, 5MTHF (active folate), and vitamins B12 and B6 (P5P) may aid the restoration of DNA methylation and inhibition of MMP-3 (see study link below). Pro-inflammatory cytokine TNF-alpha and Interleukin-1 also are key stimulators of increased MMP-1 and MMP-3 production from mast cells in many pathologies, and a number of herbal chemicals are shown to inhibit these important disease promoting imbalances. Milk thistle, curcumin (Yu jin, E zhu, Jiang huang), Gastrodia elata (Tian ma), Sinomenium acutum (Han fang ji), the herbal combination Atractylodis and Phellodendri (Cang zhu, Huang bai), Coptis Chinensis (Huang lian), and other Chinese herbs are proven to inhibit TNF-alpha and IL-1.

More information on the pathophysiology of joint degeneration is found on a page entitled Joint Degeneration and Arthritis on this website. This article concentrates on the key aspects related to clinical therapy.

Another key metabolic concern determining ossification of cartilage is the numerous enzymes involved in the destruction of the basement layer of the cartilage with proteolytic enzymes, and the turning of this material into new bone. The use of serratiopeptidase supplement may aid this cartilage ossification process. Studies with this potent proteolytic enzyme show reduced pain and inflammation in a number of pathologies, and concommittant use of seratiopeptidase with antibiotics showed a much higher delivery of the antibiotic to sites of osteoarticular infection. Past studies of various proteolytic enzymes in Europe showed in clinical trials that continuous use of simple proteolytic enzymes exerted pain relief comparable to narcotic medications with arthritic pain. New bone has abundant blood vessels, or capillaries, and is supplied with numerous enzymes in the blood. An enzyme called alkaline phosphatase probably plays a key role in new bone formation and calcification. In normal cartilage, we see little of no alkaline phosphatase, but in tissues where ossification is going to occur, large quantities of this enzyme are found. Patients with a deficient ability to produce alkaline phosphatase may have a more difficult time with healthy cartilage ossification. Decreased serum alkaline phosphatase may be due to zinc deficiency, hpothyroidism, Vitamin C deficiency, Celiac disease and malabsorption, gastric hypofunction, insufficient parathyroid function, pernicious anemia, Vitamin B6 deficiency, and folic acid deficiency. Once again, we see the potential for including the supplements zinc monomethionine, 5MTHF (active folate), B12 and P5P (active B6) into the treatment protocol. Circulating alkaline phosphatase deficiency is a well known marker for bone and liver disease as well. Calcification of cartilage is also preceded by a loss of chondroitin sulphate, and so early investigations into this process suggested that supplements of chrondroitin sulphate, as well as the nutrient glucosamine sulphate, may benefit joint health and decrease degredation. This turned out to be an overly simplistic explanation, although topical delivery of glucosamine sulphate may be beneficial in the overall protocol. Oral supplements were not found to be beneficial in large studies, probably due to the digestive breakdown of the nutrient.

The physiological factors that control the cartilage cell (chondrocyte) transformation into new bone to maintain healthy joints include growth hormones, thyroid hormones, parathyroid hormone-related peptide, as well as components of the cartilage extracellular matrix. Key enzymes that control this process are in the family of matrix metalloproteinases (MMPs), and the ability of the bone cells to invade the basement layer of cartilage as it breaks down, and form blood vessels in this tissue, which normally has no blood vessels, is very important. A number of growth factors may be very important in this mix, such as insulin-like growth factor (IGF), and vascular endothelial growth factor (VEGF). A signaling protein called Indian Hedgehog protein (IHH) is also very important, and this originates in the liver, kidney and lung, and depends upon cholesterylation to target to lipid rafts and act as a growth signal on cell membranes. IHH and parathyroid hormone-related protein (PTHrP) act in a controlling negative feedback loop regulating much of the process of cartilage transformation and growth. Studies (cited below) have found that key inflammatory mediators, or cytokines, may alter the expression of PTHrP, which acts in an autocrine or paracrine manner in local tissues, exerting hormonal effects on local hormone and cytokine receptors. Inhibiting these key cytokines found integral to osteoarthritic pathology, especially TNFalpha and IL-1, with herbal medicine, may play a valuable role in normalizing PTHrP effects on healthy cartilage ossification. The difficulty in understanding the physiology of this process is due to the holistic array of chemical signals that interplay in the various layers of the cartilage. The way to restore healthy cartilage and bone health at the joint depends upon a holistic approach to restoration, not just one chemical, one nutrient, or one process. Since the transformation of cartilage into bone at the joint is an ongoing process, no replacement of this tissue, or allopathic repair, will provide a lasting health of the joint. Only a holistic restoration of the physiological process will accomplish the task.

We see then the tools that we must utilize in this process physiologically, and the systems that we may need to restore healthy function to. Problems with thyroid, parathyroid, hypothalamic, and liver function may affect osteoarthritic degeneration. Raw materials, such as healthy bioidentical collagen matrix, or bioidentical collagen type 2, as well as glucosamine sulphate, and increased hormone Vitamin D3 with cholecalciferol supplementation, may all need to be supplied during a restoration phase. Zinc monomethionine, 5MTHF (active folate), B12, and B6 may also be needed to affect DNA methylation to inhibit MMP-3 and supply alkaline phosphatase. Herbal inhibitors of MMP-1, MMP-3, TNF-alpha, and IL-1 may be very important in the overall protocol. Healthy lipoproteins and cholesterols may also be important, and cholesterol reducing drugs may have a negative impact, inhibiting important hormones and phospholipids, as well as creating an accumulation of protein fragments. A variety of underlying health problems may be contributing to osteoarthritic pathophysiology and should be addressed in a comprehensive protocol when needed. Various nutritional deficiencies may contribute to poor cartilage to bone transformation and the patient would be wise to try supplementation for a while, as well as improve the diet. Gastrointestinal health could play a part in the pathophysiology, and resolution of such problems as gastric hypofunction and celiac disease could be essential. Such holistic treatment also has a variety of overall health benefits and is relatively inexpensive.

The role of hormones and hormonal balance in maintaining the health of bone and cartilage

While the role of the hormone that we still stubbornly call a vitamin, D3, is well known now as a key regulator of calcium metabolism and cartilage maintenance (re: normal turnover of cartilage to bone is what maintains the essential joint tissues exposed to mechanical stress), hormones are always acting in a feedback system that we call the endocrine system. An imbalance of one hormone usually signifies an imbalance of others. The complex and changing homeostasis of hormones is primarily guided by the adrenal-pituitary axis, where the kidney adrenal glands react constantly with central pituitary hormones that mainly stimulate other hormonal production. The pituitary gland is part of a complex that includes the hypothalamus, which is the primary neural regulator of hormonal balance. The thyroid gland is also a key player in the overall systemic hormonal and metabolic regulation in the body, and the parathyroids are smaller glands located in or on the thyroids. Since osteoarthritis affects women more than men, and advances dramatically in the postmenopausal, as well as the premenopausal and perimenopausal years, the subject of hormonal imbalance as one of the key aspects in osteoarthritis is much studied.

Hormonal receptors on cells may be quite numerous, with hundreds or receptors on a single cell or within it, and react to various signaling chemicals, not just a specific hormone that is the predominant hormonal stimulator at the receptor. Cartilage cells have various hormone receptor types, including estrogen receptors. Estrogens may elicit a variety of changes in the cartilage cell, or chondrocyte. Estrogen stimulation has been found to modulate the production of various growth factors, inflammatory cytokines, matrix metalloproteinases (MMPs), and reactive oxygen species (ROS). Estrogens have also been found to play a role in cartilage to bone turnover, exerting inhibitory effects on the rate of subchondral bone turnover. Thus, estrogen balance in the body is needed to maintain the complex healthy homeostatic control of the rate of cartilage to bone transformation that keeps our joints healthy. Studies have shown that estrogen replacement therapies in postmenopausal women are associated with lower incidence of osteoaerthritic progression, but the risks of synthetic estrogens have now been well documented. Natural hormonal balancing and utilization of bioidentical hormones and herbal and nutrient therapies present the woman with safe and effective treatment to restore natural estrogen balance rather than supplant it with synthetic estrogens that inhibit normal production in the body.

The hormone that we call Vitamin D3 is now found to play a dual role in hormonal regulation of the cartilage and bone maintenance, and is often deficient in patients with osteoarthritis. A 2010 study (cited below) at the Arthritis and Osteoporosis Centre at Victoria University Hospital in Cork, Ireland, found that 70% of patients newly diagnosed with rheumatic disease such as osteoarthritis were "Vitamin D" deficient, and 26% had a severe deficiency. 61% of new patients diagnosed with osteoarthritis had D3 deficiency, and the prevalence of this hormonal deficiency affected women under the age of 30 and postmenopausal women the most. Parathyroid hormone and alkaline phosphatase levels were also measured in the study and imbalances associated with both D3 deficiency and osteoarthritis and other rheumatoid diseases. There is an inverse relationship between parathyroid hormone and the hormone that we call Vitamin D (D3). Recent studies also show that not only kidney production of the D3 hormone, but local tissue production is an important regulator for cartilage cell growth and differentiation (see study cited below). The whole cellular environment is important when trying to restore this local hormonal production, and the balance of growth factors, IHH and PHTrP especially, and modulation of inflammatory cytokines, all play a role in the local expression and modulation of D3 in cartilage and joint tissues.

While clinical, or severe, manifestations of hyperparathyroid disease are not considered prevalent, the recognition that subclinical hyperparathyroid pathology, usually associated with subclinical hypothyroidism is very prevalent in modern industrialized societies (see the separate article on this website concerning this problem). The parathyroid hormones play a key role in calcium regulation and hormone Vitamin D3 level maintenance. Parathyroid hormone-like protein (PTHrP) is a locally produced protein regulator with hormonal effects that is integral to the normal maintenance of cartilage turnover. PHTrP is also highly associated with bone metastasis in breast cancer, and is identified as an integral molecule in bone destruction and excess calcium deposition in joint tissues. While pharmaceutical research looks to find novel synthetic drugs to affect or inhibit PHTrP, many patients now realize the restoration of a physiological normal PHTrP expression and modulation is the important goal in health restoration, both in treatment and prevention of osteoarthritis, and concerning the risks of breast cancer metastasis.

Plant hormones, or phytoestrogens, and their role in modulation of PTHrP, estrogenic maintenance of joint tissues, and modulation of bone and cartilage related inflammatory cytokines, has also been the focus of much scientific study in recent years. Bioflavonoids and plant lignans have evolved as an essential part of our complex hormonal physiology. This subject is particularly complex, due to the varied modulatory roles of plant hormones in the body, and the negative effects of the many synthetic estrogenic and hormonal xenotoxins now in our environment. The bottom line is that the human organism has evolved complex modulatory mechanisms to utilize plant hormones, and particularly phytoestrogens, and that supplementation with these chemicals may stimulate beneficial responses in deficient states, while overdosing is unlikely to cause problems because of the evolved regulatory modulations built into our homeostatic mechanisms. Two bioflavonoids, genistein and daidzein, have been found to increase both the production of PHTrP and the creation of PHTrP receptors with high dosage supplmentation. Low doses of these nutrient chemicals also exerted beneficial effects in studies of cellular metabolism and cytokine regulation. Most of this research has been conducted concerning breast and prostate cancers, but is applicable to osteoarthritic mechanisms.

Restoration of a healthy calcium metabolism is very important in reversing osteoarthritic degenerative joint disease, and poorly absorped calcium supplements often contribute to joint tissue calcification

Patients with a healthy endocrine system and regulation of calcium metabolism are able to utilize a variety of calcium supplements without problem. Studies have found mild benefits for a number of health problems with use of calcium supplements in these relatively healthy patients. Patients with hormonal imbalance, poor intestinal health, deficiency of activated Vitamin D3 hormone, or problems with liver and kidney health may have difficulty utilizing calcium in the diet, even when taking calcium supplements and Vitamin D3. The primary problem with absorption and utilization of calcium is gradual decrease in bone mass and strength, or ostoeoporosis. Professor K. D. Cashman of the Department of Food Science and Medicine at the University College of Cork, Ireland, wrote in an extensive article published in the British Journal of Medicine in 2002: "Because of the small metabolic pool of calcium (less than 0.1% in the extra-cellular fluid compartment) relative to the large skeletal reserve, for all practical purposes metabolic calcium deficiency probably never exists, at least not as a nutritional disorder." The problem with calcium utilization is thus not solved by taking in high dosages of supplemental calcium when there exists a metabolic health problem that is interfering with calcium utilization. An effective protocol for increasing calcium absorption into the bone involves attention to a number of physiological mechanisms that must be improved for calcium absorption to actually benefit you. There is evidence that taking calcium supplements without addressing these metabolic issues could have negative health consequences.

A long-term Women's Health Initiative United States governmental study was completed and published in 2006 inthe New England Journal of Medicine, and concluded that even among healthy postmenopausal women, calcium with Vitamin D supplementation resulted in only small improvement in hip bone density, did not significantly reduce hip fracture, and increased risk of kidney stones. This is because calcium and Vitamin D are tightly regulated chemicals in our body and when there are hormonal imbalances, these are the cause of the calcium and Vitamin D deficiencies, not just dietary insufficiency.

Pharmaceutical medicine has tried to solve this problem in a number of ways, which have had disastrous outcomes for many patients. Synthetic hormone replacement was given in the hope that osteoporosis and resulting hip fractures and other problematic bone fractures could be reduced. The Women's Health Iniative reported after a long-term study that there was a mild lowering of risk of osteoporotic fracture with HRT, yet the synthetic hormones caused an alarming number of cases of breast cancer, ovarian cancer, heart attack, stroke, thromboses, Alzheimer's, and other dementias. Reduction in the prescription of synthetic hormone after this report was dramatic, and since this time, there has been an amazing decrease in incidence of breast cancer correlated with decrease in consumption of synthetic hormone replacement. The second line of pharmaceutical treatment for osteoporosis involved the drugs Fosamax, Actonel, Boniva, etc., called biphosphonates, which theoretically work by blocking the release of calcium from the bone. In 2004, the FDA released stern warnings that a high incidence of bone necrosis was linked to Fosomax and other biphsophonate use, and in 2008, finally issued increased warnings concerning the high incidence of severe debilitating pain resulting from continued use, often with onset occurring many months after starting the drug. For many patients, these side effects did not even accompany an increase in bone density. Patients now are turning to Complementary Medicine to find an alternative to these harsh pharmaceutical treatments. Unfortunately, if you are a patient with these health concerns, simple taking of a calcium supplement and Vitamin D3 are not enough to solve the problem.

If you are reading this article to find some simple advice for success with calcium supplementation, go no further. The problem with calcium deficiency, osteoporosis, and other related health problems, is not simple. To truly correct this important health problem, the responsible person does the work, and takes the time, to understand the big picture, and to correct what has gone wrong with your health. To believe that hormonal regulation can be ignored, and that taking a calcium supplement alone will fix your problem is to pretend. To believe that taking a pharmaceutical medicine that supposedly blocks the resorption of calcium from your bone will result in a healthy state of being, when the problems with calcium metabolism are not addressed, is also a pretend state. Will prescribed synthetic hormones solve the problem? As far back as 2002, the National Institutes of Health released the results of long-term studies that showed that synthetic progestins, or progesterone derivatives, such as are prescribed in Depo-Provera and most hormone replacement and contraceptive medications, causes significant osteoporotic bone loss, even in young women. When you actually understand the sequence of events that led to your problems with calcium metabolism, only then can you correct this serious health threat with a step-by-step approach.

Deficiency of calcium is highly related to the factors that tightly control the absorption, deposition into bone, resorption out of bone, metabolism, and excretion rates of calcium. Whenever there is a calcium deficiency, the problem is not a lack of supply in our diet, but a systemic health problem with access to the dietary calcium, and the proper regulation of calcium metabolism. Calcium is found in most of the foods that we eat. It is the backbone of chlorophyll, the green substance in vegetables, and is abundant in all meats. Calcium is also abundant in many grains, beans, legumes, nuts and seeds. Mineral water with high calcium content provides a significant amount of accessible dietary calcium. You may check the calcium content of foods on a link to the UCSF Medical Center website below in the additional information section. It is time that the health community stopped pretending that the problem is solved by simple taking of calcium pills. When excess calcium is taken in the form of supplements, without the holistic correction of the underlying problem, there are significant health hazards, and these are not being addressed.

The physiological factors that determine calcium absorption, deposition into bone, resorption out of bone, metabolism, and excretion, are primarily hormonal regulation from three sources. 1) the hormone typically called activated Vitamin D3, or 1,25-dihydroxycholecalciferol, 2) regulated levels of parathyroid hormone, and subclinical hyperparathyroid, (or clinical hypoparathyroid> states , and 3) regulated levels of calcitonin hormone, with sublinical hypothyroid states. All of these basic mechanisms are strongly interrelated. Chronic deficiency of circulating calcium, even mild deficiency, can result in as much as 100 percent increase in parathyroid hormone concentration, and subsequent risk of parathyroid gland hypertrophy, and a subclinical hyperparathyroid state. These chronic mild circulating calcium deficiencies can also affect the thyroid hormone calcitonin, and contribute to mild sublcinical hypothyroid states. Problems with calcium metabolism involve a complex feedback mechanism that may result in more problems than just osteoporosis, and each aspect of this mechanism should be assessed.

Although calcium metabolism is highly regulated, we often see a relatively wide range of normal total plasma calcium concentration. This may be due to the variance in plasma protein carriers, such as albumin. It is also believed that the state of hydration can alter the albumin concentration. Now hydration would seem to be a simple matter of drinking more fluid, but physiologically, hydration involves the passage of fluid through tissue membranes and the regulation of fluid metabolism. Here too, mineral balance, hormonal balance, and healthy kidney and liver function, are all key to actual hydration health.

The most common symptoms associated with deficiency in circulating calcium include numbness and tingling, or paresthesia, as well as painful wrist and ankle spasm. Often these problems are hastily diagnosed as carpal tunnel syndrome or peripheral neuropathy, and the patient is not made aware of the potential causes of their symptoms. Lethargy, and difficulties with mental function are also frequently noted. The patient does not connect these common symptom patterns with mineral imbalances, and the mineral imbalances are not sufficiently connected to the underlying health problems. Instead, we cling to a belief that taking the most inexpensive calcium supplements available will somehow fix us. Taking quality calcium supplements in the most intelligent way, is advisable, when accompanied with holistic treatment protocol. Ignoring the problems with calcium metabolism is not advisable.

Potential Health Problems with Calcium Supplementation

Our society has been told for some time that we should take calcium supplements, and it is implied that when there is a problem with calcium in the body, all we have to do is fill the tank. When we study our body's physiology, and calcium metabolism, we find that this is patently untrue for patients with health problems that inhibit calcium regulation. There are health problems that may arise for this set of patients from taking an excess of calcium at one time, from taking the wrong type, or conjugation, of calcium, or from taking the relatively high dose of calcium with the wrong types of food, or other supplements.

The first type of problem that may arise in the patient with health problems inhibiting calcium absorption, when taking a calcium supplement, is a deficiency of phosphates. Absorption of calcium in our intestines is difficult, and when there is excess calcium in our diet, as with calcium supplement pills, another exceedingly important nutrient, phosphate, is poorly absorbed, because much of the phosphate is attracted to the calcium and forms insoluble calcium phosphate molecules that cannot easily pass through the intestinal wall, and so are excreted with the feces, or worse, accumulate in the intestinal tissues, causing calcification, potentially contributing to formation of calcium urinary stones.

This is because phosphate and calcium are highly charged ions, and calcium is electropositive while phosphate is highly electronegative. Normally, phosphate is easily absorbed, but in the presence of excess calcium, it is very poorly absorbed. This causes health problems beyond the inhibition of calcium absorption, because phosphate molecules are very important to bodily function. One example of phosphate metabolism is the molecule adenosine triphosphate, which essentially provides power for our muscles. Phosphate is a simple molecule, with phosphorus surrounded by four oxygen radicals. Oxygen is an ion that provides most of the direct energy in our body, and in many patients, the oxygen needs increase when we have a worsening chronic musculoskeletal problem. Deficiency of phosphate may contribute to the chronic pain syndromes that so many patients complain of. Also, when the ration of calcium to phosphate is altered, and the product of concentrations of calcium and phophate exceeds 70, precipitation of calcium phosphate crystals in soft tissue is much more likely. Calcified joint tissues create arthritic conditions and gradually result in such problems as the "frozen shoulder" syndrome. The first significant problem with calcium supplementation is thus problems with intestinal absorption and potential phosphate deficiency over time.

A related problem involves poor quality phosphates in the diet. Soft drinks are high in phosphorus, and excess meat and simple carbohydrates, such as unrefined sugar and refined flours, all create excess phosphates that bind to the calcium we eat and cause the calcium to be bound and excreted. There has been a clinical observation and warning for some time concerning patients with endocrine deficiencies and poor calcium metabolism and the regular consumption of soft drinks, excessive red meat, and high glycemic index carbohydrates.

We see that when we actually pay attention to our basic physiology, that medical advice driven by market forces, or given by physicians that have been trained to treat serious disease, and have little knowledge of nutrition and healthy physiology, may cause serious problems for us.

In one of the foundation texts of the study of medicine, Guyton and Hall's Human Physiology and Mechanisms of Disease, the author states that "about seven eighths of the (normal) daily intake of calcium is not absorbed, and therefore excreted in the feces; the remaining one eighth that is absorbed is used mostly for formation of bone, and the excess (not allowed in this process) is eventually excreted in our urine." If the calcium excreted in the urine is bound to specific chemicals, such as oxalic acid, this may contribute to kidney stone formation. The authors, who are perhaps the most prominent physiologists in the world, devote an entire chapter to the problems of calcium absorption, deposition into bone, resorption from bone, and utilization in the body.

Calcium is the most regulated molecule in our body. This is because it is a large mineral molecule that is highly electropositive and attracted to other molecules, and plays an extremely important role in many of the cells and tissues of our body, both in muscles, bones and organs. When there is a problem with the complex regulation of calcium in our bodies, various health problems occur, with the most publicized problem being osteoporosis, or weakening of our bones. Simple taking of calcium supplement is problematic because even absorption of the calcium pill in the gut is highly regulated and dependant on a number of factors, especially levels of the hormone that our various forms of Vitamin D promote, and parathyroid hormone. Calcium is poorly absorbed from the intestinal tract because of both the relative insolubility of its chemical compounds, and also because large molecules do not readily cross through membranes. Active calcium transport is dependant on a carrier protein, both in the small intestine and in the colon, called calcium-binding protein, that is an expression of Vitamin D metabolism. This Vitamin D metabolism involves hormonal activation in the kidney regulated by parathyroid hormone, and healthy protein metabolism of the liver.

How regulated is the calcium metabolism? To illustrate, calcium absorption alone, meaning the amount of calcium that your consume, either in food or with calcium pills, is highly regulated by a hormone that is activated from circulating Vitamin D in your kidney. One form of this Vitamin D, cholecalciferol, is stored in your liver, and converts to 25-hydroxycholecalciferol. When there is too much of this form of Vitamin D, it inhbits more conversion. When the 25-hydroxycholecalciferol circulates to the kidney it can be transformed into the active hormone 1,25-dihydroxycholecalciferol, but needs a regulated level of parathyroid hormone to achieve this hormonal conversion. Small variances in circulating calcium levels highly affect the levels of parathyroid hormone. The activated hormone D3 targets many tissues in the body, including the intestinal lining, and the liver, affecting the calcium-binding protein, and enzymes that are needed for calcium absorption. When any of these factors are negatively influenced, circulating calcium is decreased, which immediately affects parathyroid hormone levels, as well as thyroid calcitonin. As complex as this elaborate feedback system of regulation sounds, the actual mechanism of calcium regulation is even more complex. This tells us that it takes more than just taking some calcium supplement to correct our calcium deficiency.

A treatment protocol that actually works

There are a number of health factors that you need to familiarize yourself with if you are to succeed with restoration of a healthy calcium level in your bones and circulating to your tissues. The common reaction to our complex health problems, especially hormonally related health problems, is to grasp for the simple magic pill solution. You can't be blamed for this desperate reaction, because of course everyone wants this magic pill solution. There are many people around you that reinforce this simplified belief system, because it sells products very efficiently. If one person tells you that all you have to do is to take a certain calcium product, poor quality Vitamin D, and synthetic hormone replacement, and another person tells you that the solution is a lot more complex than that, you naturally believe the first person. This article is written to tell you the truth about what you need to do to actually get healthy. Despite what the pharmaceutical giants and ridiculous TV ads tell you about the guaranteed success of harsh medications to correct osteoporosis and calcium deficiency, the clinical picture has not shown proof of this success. The patient that seeks understanding and guidance in an intelligent approach to their problems, is sure to find health and success that can translate into so many different benefits. This proactive approach is worth the trouble, but requires some integration of your standard health care with Complementary Medicine.

A number of types of calcium supplement are available on the market, and the general impression is that if you take the right type of supplement that you are guaranteed to increase the calcium deposition into your bones. While this may be correct if the patient is relatively free of problems that may affect calcium regulation, for most patients with a need for calcium deposition or circulating calcium, there exists various problems that will make simple calcium supplementation ineffective for them. Obviously, each person has a unique health makeup, and finding the right way to correct calcium deficiency involves attention to a number of details. Your physician often lacks the time needed to address these details on an individual basis. Since the problems with calcium metabolism are not considered a significant health problem, the physician will almost always just prescribe calcium supplements, sometimes with magnesium and Vitamin D. It is up to the patient, with analysis and guidance from a knowledgeable Complimentary Medicine physician, to take control of this somewhat complicated problem and make it work.

The most widely prescribed calcium supplement, calcium citrate, renders the circulating calcium non-ionized. Even if this calcium supplement is absorbed through the lining of the intestine, a non-ionized form of circulating calcium is able to pass into tissues through the capillary beds, but is not able to be utilized directly for use, since it is not ionized. Excess amounts of calcium citrate, and other forms of supplemental calcium, are thus deposited in the joint tissues through the capillary bed, and cause excess calcification of the joint, often resulting in frozen shoulder syndrome, which involves calcific capsulitis. Other tissue calcification pathologies also may occur.

To make calcium supplementation actually work for you, you absolutely need to understand the factors that control absorption, deposition, and utilization of calcium in your body. Without addressing these factors, calcium supplementation may be a waste of money, or worse, contribute to calcium deposits in your joints and tissues, as well as potentially contributing to the formation of calcium urinary kidney stones.

The basic needs of the human body in the absorption, deposition, resorption, and utilization of calcium involve these factors: 1) a consistent supply of stored or ingested Vitamin D, in various forms; 2) a hormonal balance that provides consistent parathyroid hormone for conversion of the prohormone Vitamin D types to the D3 hormone; 3) healthy liver function; 4) healthy kidney function; 5) healthy intestinal epithelium, or membrane lining; 6) healthy formation of calcium-binding protein and certain enzymes, primarily in a healthy liver, and 7) healthy thyroid metabolism, our source of regulated hormone calcitonin. While this scenario is more complicated than we would like, this is the truth. It takes a holistic health approach to effectively create a healthy calcium and Vitamin D metabolism. Simply taking calcium and Vitamin D, in whatever form, dosage, or quality, is insufficient to guarantee success with health problems related to poor calcium metabolism, such as osteoporosis. The good news is that attention to these health problems will result in improved health and quality of life beyond the treatment of osteoporosis, and will be worth it in the long run.

Estrogen deficiency is also primarily linked to osteoporosis. This is because the estrogens also promote calcium deposition into the bone. Some female athletes may induce an estrogen deficiency, and this produces an abscence of menstruation in many young female athletes. Heavy exercise also may hinder calcium uptake. Eventual risks of weakened bones and other health problems increase for this subset of women. For these young female athletes, proper calcium supplementation will have noticeable benefits. For the estrogen deficient older woman, the benefits from simple calcium supplementation will not be apparent. Estrogen deficiency, like most hormonal problems, is best treated by restoration of the whole endocrine system.

Estrogen deficiency is linked to osteoarthritis is less understood ways. The prevalence of osteoarthritis is much higher in women than men, and in women the disease progesses dramatically in postmenopausal states. Estrogen replacement therapies have consistently been linked with overall lower prevalence of osteoarthritis, although the health risks of synthetic estrogens have discouraged prescription and usage since the large Women's Health Initiative studies of 1999. Bioidentical hormones and hormonal balancing have seen a great upsurge in development and popularity, though, and are a proven way to prevent osteoarthritic progression in the postmenopausal state of estrogen deficiency. Correction of hormonal imbalance in premenopausal states may be very important to the progression of the disease as well.

The forms of Vitamin D prohormone and D3 hormone itself, the key to calcium regulation

The hormones called activated Vitamin D3 or D2 control both absorption of calcium in the gastrointestinal tract, deposition into bone, and resorption into the circulation. This hormone Vitamin D3/D2 is not the same as the vitamin supplements that you consume, which have no physiological activity of their own, but must be converted to active hormone in the kidneys or other tissues. There are a number of molecules in the body that are called Vitamin D, with 5 distinct types of prohormone, and numerous metabolites of these prohormones. In the past, vitamin supplements used one of these metabolites that was the cheapest, and most easily assimilated. This created potential problems if taken in high dosage, relating to imbalance of the various forms of Vitamin D in the body. Finally, Vitamin D3 was routinely prescribed, in one of 2 forms, cholecalciferol, or 25-hydroxycholecalciferol (calcitriol). Cholecalciferol is the form that our bodies generally utilize, is stored in our liver in this form. D3 cholecalciferol is derived mainly from a type of cholesterol that is stored in our skin and activated by direct strong midday sunlight, though. This mechanism is our chief source of cholecalciferol Vitamin D3, and is itself highly regulated. Studies show that exposure to weak sunlight has much less effect, and that exposure to midday sunlight for more than 10 minutes triggers a mechanism that stops the cholecalciferol from forming. In the diet, cholecalciferol is generally derived from meat sources. Cholecalciferol goes through a number of transformations before it becomes the molecule that stimulates the formation of the hormone active Vitamin D3. Plant sources of this prohormone are called Vitamin D2, which is perhaps equally as effective in stimulation of the formation of active Vitamin D2 hormone. All of the conversions of the 5 types of Vitamin D prohormone to active D hormone are dependant upon parathyroid hormone, and hormonal balance, as well as phosphate levels and circulating calcium ions. Problems with protein metabolism and body acidity may also affect these regulating cofactors indirectly. This is the holistic catch to calcium metabolism. No matter what form or dosage of Vitamin D, or what form or dosage of Calcium that you take, unless there is a hormonal balance, healthy metabolism, and regulation of acidity, there will be dysfunction and deficiency of calcium. Since calcium is the chief neutralizer of body acidity, an unhealthy chronic cycle may occur.

When modern medicine attempted to supplement this Vitamin D3 hormone directly, we found that serious health problems occurred because it was difficult to prevent overactivity by this increase in activated Vitamin D3 hormone. This course of therapy was discontinued, which shows the need to restore healthy natural hormonal balance in the body.

Science has understood for many years that there are at least 5 types of prohormone, or hormone precursor, called Vitamin D. All 5 of these Vitamin D forms can be utilized by the body to create the two forms of hormone D3, 1,25-Dihydroxycholecalciferol and 24,25-Dihydroxycholecalciferol, in your kidneys. They have also known that that there are at least 20 metabolites of these 5 Vitamin D prohormones that do not convert to D3 hormone, but play various roles to keep our body healthy. Recently, research has uncovered the fact that the various forms of Vitamin D play important roles in most cellular processes in the body, making it one of the most important regulatory cofactors in the human body. Serious cardiovascular pathologies have now also been linked to Vitamin D deficiency. Unfortunately, there is tight regulation of this group of vitamins, and high dosage of a particular type of Vitamin D may contribute to poor regulation in the body. Nature has provided us with a large variety of sources of the various Vitamin D molecules, including many dietary sources, metabolic sources, and even production of the vitamins by the healthy flora and fauna in our intestines. We also have a complex metabolism to insure that the various metabolites of Vitamin D are produced in relation to need. To really achieve success, we need to make this system work.

Most of the hormone D3 that is created, or activated, in a healthy kidney metabolism is derived from 7-dehydrocholesterol in the epidermis of the skin, when the skin is exposed to direct sunlight of a narrow wavelength of UVB 270-300 nanometers for approximately 10-15 minutes. This creates cholecalciferol, or Vitamin D3. Sufficient supply should result if you expose your face, neck, hands and arms outside to direct sunlight at midday 2-3 times per week. The same prohormone Vitamin D3 cholecalciferol can be added to your system by taking a pill. The question is whether the oral intake of cholecalciferol is being absorbed. Studies that show that Vitamin D intake in a select population does not produce the desired results, and like our calcium deficiencies, reflects the fact that our Vitamin D metabolism is not so simple as just filling up the tank. Vitamin D2, the prohormone derived from plant sources, can also be taken orally, and is called ergocalciferol, although some studies have indicated that it is much less effective than D3 cholecalciferol in preventing osteoporotic bone fractures.

The regulation of calcium metabolism and the rate of conversion of Vitamin D prohormones of activated Vitamin D hormone in the kidney is so important to our health that our bodies have 7 additional metabolic factors in addition to parathyroid hormone that control the D3 hormonal conversion. These are endocrine modulators, estrogens, calcitonin from our thyroids, growth hormone and prolactin from our pituitary gland, insulin, and cortisol. The variety of health problems that could effect D3 hormonal conversion and calcium metabolism are thus numerous, including endocrine imbalance, emotional stress affecting the hypothalamus, subclinical thyroid and parathyroid dysfunction, hormonal imbalance in the menstrual cycle, insulin resistance in diabetes or metabolic syndrome, and adrenal stress syndromes. Various medications, especially synthetic hormones, could have a significant effect on this D3 hormone metabolism. When there is a calcium problem in the body, it is best to just admit that you need to work to achieve better overall health, and to do this, you need to see a Complementary Medicine physician with knowledge of this physiology, and take a comprehensive holistic approach.

The different types of calcium supplement; pros and cons

To repeat, there is no actual nutritional deficiency of calcium, only a problem with the regulation of calcium metabolism in the body. Calcium supplements may be of very limited benefit, and calcium is found in a wide variety of foods, which generally give a more bioavailable calcium. Nevertheless, some patients may still benefit from calcium supplements.

A large variety of scientific studies are conducted to determine the benefits of one type of calcium supplement over another. Many of them report contradictory findings. Study design, differenced in the health profiles of participants, and means of measurement account for much of this manipulation. Since measurement of actual calcium bone deposition is problematic, much study data relies on animal studies, which may not reflect human physiolgoy exactly. Different types and conjugations of calcium supplement do have different profiles for reaching targeted tissues or bone deposition. Here again, there seems to be no simple answer to the question of which type to take. Below are some helpful pieces of the puzzle.

Calcium carbonate contains the highest percentage of elemental calcium, up to 40%, depending on quality. Calcium citrate contains about 21%, calcium gluconate 9.3%, and calcium lactate 13%. On the surface, this would seem to imply that calcium carbonate and citrate were the best forms, but this is misleading. Studies have shown that despite the percentage of calcium, nearly the same amount is absorbed for each type, implying again that other factors determine bioavailability. Numerous studies have shown that organic salts, such as gluconate and lactate, provide much better bioavailability than inorganic salts such as carbonate or phosphate, though. Solubility of the form into ionized calcium is also considered when addressing bioavailability. Labels are sometimes misleading, implying that there is 1000mg of calcium, when actually there is 1000mg of the conjugation, with as little as 10% being actual calcium.

The different types of calcium conjugations allow for the calcium to be broken down in different ways. These molecules may be dissolved in water, broken down by stomach acids, or carried in a conjugated state by calcium-binding protein, which is created in accord with levels of a hormone activated from Vitamin D prohormone. The different forms have various bioavailability profiles, but actual absorption is still completely dependant on the D hormone. If the stomach acids are not healthy, increased water solubility may help bioavailabilty. Flora in the lower gut that favors acid states, such as acidophilus, may increase absorption here.

Calcium lactate can be absorbed at a wider variety of pH, or acid-base, states, and is better absorbed because of this. This salt is used in baking powder, found in aged cheeses, and antacids. Products that contain calcium lactate derived from natural fermentation are purportedly even easier to assimilate.

Calcium gluconate-lactate is often recommended for deficient calcium states. despite the fact that you have to take a large number of pills to provide 1000 milligrams of elemental calcium, commonly 10-20 per day.

Studies have found that calcium absorption and bone deposition from drinking mineral waters with high calcium content was excellent. This is a healthy dietary source of calcium, and the natural array of minerals helps increase the bioavailability of calcium.

Many multimineral and multivitamin products use D1-calcium-phosphate in their products. This type of calcium is insoluble and interferes with the absorption of the nutrients in the multinutrient product.

Calcium formate is a relatively new form of calcium salt created to provide increased bioavailability. Studies show that calcium formate is superior to calcium citrate and carbonate in delivery of calcium to the bloodstream and depression of serum parathyroid hormone. Calcium formate also has a lower molecular weight, high percentage of calcium content, and high water solubility at neutral pH.

Coral calcium is a type of chelated natural calcium that is balanced in nature with a number of other minerals for improved bioavailability. Small studies have shown that is appears to absorb a little better than calcium carbonate supplement, and has a greater effect on neutralizing endemic acidity. It is more expensive and widespread use may add to damage of the coral reefs, though. Nevertheless, coral calcium has some advantages. It easily becomes ionic in water, called solubility, and hence, may benefit tissue problems and cellular metabolism better, and may be more bioavailable for people with poor stomach function. Some studies claim that other health advantages are linked to calcium aspartate found in the coral calcium.

Calcium aspartate has been effectively utilized to reduce muscle spasm and aid the contractile physiology in chronic myofascial pain syndrome. Aspartate is a form of aspartic acid, that is utilized in neuromuscular tissues to produce ATP and energy. Aspartate is also part of key ion channel receptors in the nervous system, such as N-methyl-D-aspartate, or NMDA, receptors. These receptors linked to neural synapse strength, neuron survival, and neuron protection. Calicum ion activates these receptors, and calcium aspartate, if utilized by our tissues properly, could both supply ionized calcium and components beneficial to the muscles and nerve cells. Asparate may also be more bioavailable in the lower gut with health flora and fauna, which break down aspartate easily into various components, and is an acidic amino acid, also accounting for increased calcium bioavailability.

How to best utilize calcium supplements and maximize the absorption and utlization

After addressing the systemic issues, such as Vitamin D deficiency, hormonal imbalance, liver function, and the array of issue mentioned above, the taking of calcium supplements will work best if you observe a few rules of physiology. Calcium supplements should be taken with calcium rich foods, and foods that are rich in mangnesium, chlorophyll, and other minerals. Paul Pritchford, the famed nutrient expert, recommends taking the supplements in smaller doses spread through the meals, and eaten with whole grains, legumes, leafy greens and seaweeds. The exception would be foods containing oxalic acid, such as chard, kale, rhubarb, cranberries, plums, almonds and cashews. If the oxalic acid binds to the calcium, it forms an insoluble salt that cannot be absorbed, and may be excreted in the urine, contributing to kidney stone formation. Excess zinc can easily interfere with calcium absorption, so taking calcium supplements with other drugstore products containing zinc should be avoided. Taking calcium with iron reduces the effect of both minerals, and this concurrent intake of iron supplement with calcium supplement should be avoided.

Paul Pritchford also recommends taking the calcium supplements with plenty of green vegetables (except oxalate-rich kale, chard and spinach), and take them with a mineral rich product, like alfalfa or barleygrass supplements, or kelp powder. Red clover is also mineral rich, and has been shown to be an effective aid in treatment of menopausal and postmenopausal syndromes. If the calcium supplement contains smaller amounts of magnesium, selenium, manganese, and iodine, this may also improve absorption. Silicon-rich foods may also benefit the calcium deficiency. These include whole cucumbers with the peel, celery, strawberries, parsnips, dandelion greens, steel cut oats, millet, buckwheat, and brown rice. A leafy green that is recommended with calcium supplements is chard, a highly nutritious green.

Recent research has sought other products that may increase intestinal calcium absorption. Inulin and oligofructose combined resulted in an 18% increase in true fractional calcium absorption. Inulins are naturally occurring polysaccharides produced by fibrous portions of plants. Altered inulins are often used in processed foods, but sources from fresh leafy green vegetables are important and explain why calcium supplement is best utilized when taken with these foods. Plants that contain a concentrated amount of inulin include onions, garlic, jicama, dandelion, burdock, Jerusalem artichoke, and the medicinal herbs Elecampe (Inula helenium) and Wild yam (Dioscorea). Oligofructosides are also important in aiding the colonization of the intestines with beneficial symbiotic bacteria (probiotics).

Reducing bone loss when there are problems with hormonal deficiency or other causes of calcium deficiency has also been a subject of scientific study. Researchers at the University of California San Francisco found that controlling acid states with potassium bicarbonate improves calcium and phosphorous balance, reduces bone resorption, and increases the rate of bone formation.

Here is a step-by-step logical guide to correcting these problems:

Clearly define your symptoms

symptoms are not something we like to think about, especially when they are chronic. You need to overcome this aversion and clearly define, in writing, what are your symptoms, so that the exact cause of these symptoms can be discovered and treated. Treatment of symptoms is the first step in your recovery, but is not the most important step. To insure sustained benefit, actual reversal of damage to the physiological function in your body must be achieved, and this is not always evident by looking at the symptoms. If you stop your recovery when your symptoms subside, you are not achieving your goals. As you can see by reading the article above, a number of aspects of your health need to be addressed with calcium deficiency, and some of these are subclinical states, meaning that they may not produce significant symptoms. Objective analysis with simple tests that measure active hormonal metabolites and cofactors, and comparison to your symptoms and health profile is very helpful.

Let a Complementary Medicine physician, such as a Licensed Acupuncturist, clearly analyze and explain your health profile, so that a successful long-term strategy can be devised to regain a healthy calcium metabolism

When you utilize a professional to guide your return to healthy endocrine function and calcium regulation, you are assured that this gradual return to optimal health is proceeding properly despite the complexities. In the long run, you will find that the quality of life is also improving, as these various aspects of your health are improved. Other health problems that we worry about with aging are also prevented. The time to stop pretending that simply taking a commercial calcium pill will reverse this complex problem is now.

Understand how the drugs you take, or other therapies work

Sometimes, medication can solve one health problem but cause other significant health problems. A number of medications may affect your endocrine health or liver function, and a larger number may have a detrimental effect on the gastrointestinl health with chronic use. When you know the mechanism of damage, reversal of this damage can be achieved in your therapy. For instance, if you took Interferon, you will note that this drug works by genetically inhibiting protein expression, especially in the liver. After the therapy, liver function and protein expression needs to be enhanced again. Certain nutrient supplements greatly aid this process, such as B vitamins, and these supplements should be combined with foods containing them to insure greatest utilization. A variety of supplements can target certain metabolic problems. Herbal strategies can be used to improve liver function, and utilization of a knowledgeable herbalist can solve many problems. Acupuncture stimulation will be very effective to encourage improved physiological function and will work to increase the effectiveness of the supplements and herbal formulas. Discuss this process with your physician.

Help your body to help itself

The body has a natural mechanism to repair damage, called the immune system. This complex system can be made to work better by both utilizing specific herbs, supplements and acupuncture, and also by decreasing physiological stress and improving general health. Your body has certain limitations or tolerances for stress. When these limitations are exceeded, your immune system will not work effectively. Stress is defined as the physiological needs in the body, not just work deadlines and emotional situations at home. Each individual has a certain capacity for stress. The less healthy you are, the less stress tolerance that you have. To decrease stress and improve your physiological tolerances, you need to decrease work, emotional aggravation, and exposure to harmful chemicals. To improve tolerances, you need to increase therapies, healthy diet, healthy exercise, sunlight, fresh air, and restful periods. You may need to discuss a temporary reduction in the amount of medication that you consume with the prescribing M.D.. When you do all of these things positive results will happen. When you fail to do these things, you will perpetuate your problem. Changes in your lifestyle are difficult, but not as difficult as the changes to your lifestyle that will be forced on you if you don't temporarily deal with restoration of your health.

I hope this short guide to therapy is helpful to you in organizing your physical recovery. You need to work with your physician to insure that this process works as well as you want it to, and stick to a guided therapeutic course till you achieve your goals. Don't let worry consume you and prevent positive action. You also need to address the mental problems that often accompany these harsh therapies, such as depression and anxiety. I hope that I can be your guide to a full recovery.

Information Resources

The number of sound scientific studies of Chinese herbs that are helpful in the treatment of osteoarthritis is now large and varied, and while few large acupuncture studies have been accepted by Western medical journals, sound and consistent evidence of a variety of benefits in the treatment of osteoarthritis is seen. A few examples of the quality of evidence are presented below. While no specific treatment, and no pharmaceutical medication, has been proven highly effective in reversing osteoarthritic mechanisms alone, an integrated protocol utilizing a variety of effective treatment options is now the consensus for the most effective approach to treatment. When reviewing Complementary Medicine and the array of treatments offered by the Licensed Acupuncturist and herbalist in TCM, keep in mind that there is an array of benefits from these therapies, rather than the specific single mechanism seen in allopathic treatments. The whole array of therapeutic benefits is what makes holistic medicine viable, and these may be increased by combining acupuncture, electroacupuncture, herbal and nutrient medicine, soft tissue physiotherapies, and instruction in therapeutic protocols in the same treatment session. While standard studies of benefit only address one aspect at a time, these treatments actually provide a synergistic array of benefits, most of which are not mentioned in the study report, which is just focused on one treatment aspect.

  1. Studies in 2008, at both the Harvard Medical School and associated Massachusetts General Hospital, in Boston, Massachusetts, U.S.A., as well as the University of Berne, Switzerland, found support for the 40 year-old theory that most osteoarthritis of the hip is a combination of primary and secondary causes, slowly developing, and may be corrected at an early age. Most cases of hip osteoarthritis are not diagnosed until a late stage of the disease, spurring the need for a problematic hip prosthesis, because symptoms are usually mild until the cartilage of the femur is nearly gone and the joint acetabulum degenerated severely. While these experts call for early diagnosis with MRI and surgical correction to stop this progression, integration of Complementary Medicine could also help prevent the future need for a hip replacement or debility. The main secondary causes are mechanical impingement of the femur and acetabulum, usually at the anterior superior aspect and altered internal rotation in 90 degree flexion (sitting), and correction of stabilizing forces with myofascial release and neuromuscular reeducation could correct these impingement forces. Increased quality of instruction in body mechanics and self-administered therapies, physiotherapies, acupuncture, herbal and nutrient medicines, and a greater awareness of secondary causes, such as corticosteroid use, substance abuse, and side effects of biphosphonates and synthetic hormones could also be integrated to create a more effective preventive protocol: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2505145/
  2. A 2013 meta-review of all published scientific studies of acupuncture to treat osteoarthritis, by the University of York, United Kingdom, found that "acupuncture can be considered as one of the more effective physical treatments for alleviating osteoarthritis knee pain in the short-term". The difficulty in designing large human clinical trials with so-called placebo acupuncture that is blinded to both the patient and the administering physician has significantly hampered the ability to provide the high-quality large-scale human trials to positively prove that acupuncture and electroacupuncture work definitively better than placebo, but all studies show significant benefits over the last decade, and numerous laboratory studies elucidate how this stimulation acts to increase and encourage regrowth of tissues, including cartilage. No significant large, long-range human clinical trials exist yet, as of 2014, due to these study design problems : http://www.ncbi.nlm.nih.gov/pubmed/23973143
  3. A 2010 meta-review of all published scientific studies of acupuncture to treat osteoarthritis, by the esteemed Cochrane Database Systems Review, showed that so-called placebo or sham acupuncture double-blinded human clinical trials, which are very problematic to design, as blinding the patient and the administering physician to a needle stick and manipulation is perhaps impossible, do nonetheless show significant benefits, albeit modest over the so-called sham acupuncture, which is often just other needle points that are intrinsically effective as well in the treatment, and deny the physician the ability to effectively manipulate the needle to achieve better effects. This meta-review notes that other types of human clinical trials, that compare real acupuncture stimulation to no stimulation, but the expectation of stimulation in the near future (waiting list), show much more significant benefits, and in fact often show benefits that exceed standard protocols. Such results are systematically downplayed with the use of the language in the these study reports and reviews in the West, and this bias has even been studied and criticized by organizations concerned with medical scientific study in the West: http://www.ncbi.nlm.nih.gov/pubmed/20091527
  4. A 2012 updated meta-review of all published scientific studies of acupuncture to treat osteoarthritis, by the Shanghai Jioatong University Department of Orthopedic Surgery, in Shanghai, China, concluded that "acupuncture provided significantly better relief from knee osteoarthritis pain and a larger improvement in function than sham acupuncture, standard care treatment, or waiting for further treatment (no treatment)". This update reflects changes in the last 2 years reflecting reform of study design, which was used to achieve bias against acupuncture in treatment for decades. This meta-review also shows that acupuncture outperforms standard therapy, which studies have shown for some time, but was downplayed with a summary that stated that it was unclear if true acupuncture significantly outperformed so-called "sham or placebo" acupuncture: http://www.ncbi.nlm.nih.gov/pubmed/22588814
  5. Studies in 2013, at Peking Union Medical College, in Beijing, China, showed that electroacupuncture stimulation could effectively improve both symptoms and function in osteoarthritic joints (the knee is often studied, but rarely the hip), and has proven positive influence on T2 value in cartilage, a value used in MRI studies to determine the quality of the cartilage: http://www.ncbi.nlm.nih.gov/pubmed/23713295
  6. Studies in 2011, at Peking Union Medical College, in Beijing, China, found that electroacupuncture could also down-regulate the expression of pro-inflammatory cytokines IL-1beta and TNF-alpha in osteoarthritic chondrocytes (cartilage-producing cells), and has an effect similar to the pharmaceutical inhibitor Diclofenac (an NSAID - Voltaren Gel, Voltalin, Flector, Cataflam, Solaraze - similar to Naproxen), making electroacupuncture a valuable adjunct treatment for osteoarthritis: http://www.ncbi.nlm.nih.gov/pubmed/22007590
  7. Studies in 2011, at Peking Union Medical College, in Beijing, China, found that electroacupuncture could also upregulate the expression of TIMP1 and modulate MMP expression to benefit the repair and maintenance of articular cartilage in osteoarthritis: http://www.ncbi.nlm.nih.gov/pubmed/21644313
  8. Studies in 2002, at the Osteoarthritis Research Unit of the hospital at the University of Montreal, Quebec, Canada, found that IL-1beta and TNF-alpha are key cytokines related to the pathology of osteoarthritis, and should be targeted in therapy, achieving downregulation or modulation of expression. Upregulation of TIMP1 and modulation of MMP-1 and 3 are also valuable goals, providing enzymes that speed clearance of metallic protein peptides that contribute to the degenerative disease. Electroacupuncture has been proven to achieve both of these goals while relieving pain and aiding function: http://www.ncbi.nlm.nih.gov/pubmed/12082286
  9. A study at the University of Texas MD Anderson Cancer Center, in Houston, Texas, showed that a simple acupuncture treatment using just 3 points significantly relieved pain and improved joint function and mobility in study chimpanzees with severe osteoarthritis and debility. Such study cannot logically depend on a "placebo effect" as was alleged in standard medicine for decades concerning acupuncture, and still is by some medical doctors in published blogs: http://www.ncbi.nlm.nih.gov/pubmed/23849446
  10. Studies in 2005, at Seoul National University, in Seoul, South Korea, found that a Chinese herbal formula in alcohol extract, PG201, is effective to treat collagenase-induced osteoarthritis, by downregulating expression of the pro-inflammatory cytokines IL-1beta, TNF-alpha, and PGE2, as well as nitric oxide (swelling), reducing cartilage erosion. This formula, also studied and found effective for treatment of Rheumatoid Arthritis (Rheumatology, Oxford Journals, Shin SS et al, 2003; 42(5): 665-7), consists of Chaenomelis Fructus (Quince), Achyranthis Radix (Niu xi), Carthami Flos (Hong hua), Cnidii Rhizoma (She chuang zi), Cinnamomum Cortex (Rou gui), Angelica Radix (Du huo), Gastrodiae Rhizoma (Tian ma), Ledebourieallae Radix (Fang feng), Gentiana Macrophylla Radix (Qin jiao), Acathopanacis Cortex (Wu jia pi), Phlomidis Radix, and Clematidis Radix (Wei ling xian), is typical of Chinese Herbal Formulas to treat arthritis: http://www.ncbi.nlm.nih.gov/pubmed/15883039
  11. Studies in 2010 at Kyung Hee University in Seoul, South Korea, found that the Chinese herb Phellodendron amurense (Huang bai) inhibited cartilage degeneration in osteoarthritis, exerting multiple effects on enzymes, MMP activities, kinases, and other signaling proteins: http://www.ncbi.nlm.nih.gov/pubmed/21182922
  12. Studies in 2010 at National Taiwan University found that a chemical in the Chinese herb Dang gui (Chinese Angelica sinensis) decreased inflammatory cytokines and MMPs integral to cartilage degeneration in osteoarthritis: http://www.ncbi.nlm.nih.gov/pubmed/20349328
  13. Studies in 2008 at Kyunhhee University in Seoul, South Korea, found that the Chinese herb Siegesbeckia pubescens (Xi xian cao) exerted significant cartilage protectant effects via down regulation of key inflammatory cytokines, aggecanase enzymes, and MMPs, while upregulating TIMP-1: http://www.ncbi.nlm.nih.gov/pubmed/18635922
  14. Studies in 2010 at Cardiff University, United Kingdom, found that the Chinese herb Boswellia frereana (frankincense resin, or Ru xiang) was proven to exert inhibition of cartilage breakdown via inhibition of key inflammatory cytokines and MMPs. Epi-lupeol, a triterpene was considered that main active chemical. http://www.ncbi.nlm.nih.gov/pubmed/19943332
  15. Studies in 2009 at Kyunghee University, Seoul, South Korea, found that the Chinese herbal formula KHBJ-9B showed increased efficacy over single herb extracts to prevent cartilage and collagen type 2 degeneration, and inhibit the pro-inflammatory cytokines IL-1beta and TNF-alpha significantly, and downregulated MMP-1, MMP-13, and ADAMTS-4 and 5, as well as upregulating the TIMP-3 in human cartilage, exerting an array of chemical benefits to promote renewal of cartilage in both osteoarthritis and rheumatoid arthritis. Some of the herbal chemicals in the formula, betulin, premaradienoic acid, and betulinic acid, which are found in Sophora japonica (Huai hua mi), Betula papyrifera, or Heart wood, Salvia miltiorrhiza (Dan shen), Zizyphi spinosae (Suan zao ren), and other herbs :http://www.ncbi.nlm.nih.gov/pubmed/19100343
  16. Studies in 2012, at Kyung Hee University, Seoul, South Korea, demonstrated that the Chinese herbal formula WIN-34B moderately suppresses cartilage destruction by inhibiting matrix metalloproteinases (MMPs), and key inflammatory mediators (IL-1beta and TNF-alpha). The formula contains the herbs Lonicera japonica (Jin yin hua) and Anemarrhena asphodeloides (Zhi mu): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3559294/
  17. Studies in 2012, at the National Defense Medical Center and Graduate Institute of Medical Science, in Taipei, Taiwan, found that the supplement Pycnogenol, derived and standardized from maritime pine bark and combined with mixed tocopherols, was effective in treating arthritis induced by crystals such as urate or calcium, in gout or calcified capsulitis: http://www.ncbi.nlm.nih.gov/pubmed/22198264
  18. A 2013 meta-review of all human clinical trials of topical herbal remedies for osteoarthritis of the knee, by the esteemed Cochrane Database System, and the University of the Sunshine Coast School of Health and Sports Sciences, MaroochydoreDC, Australia, found that while only 7 studies were published that met the criteria, these did involve 785 patients, and revealed that simple topical herbal medicines, such as arnica and comfrey, improved symptoms as well as pharmaceutical topicals with NSAIDS, reducing pain after 3 weeks by about half, and that the mechanisms of action of these herbs, improving tissue health, provided a rational basis for their use in standard treatment of osteoarthritis. Capsaicin ointment did not significantly improve symptoms, but this is expected, as capsaicin works by affecting the mechanisms of nerve-related pain, or neuralgia, not arthritic pain: http://www.ncbi.nlm.nih.gov/pubmed/23728701
  19. A meta-review of all published scientific studies of non-pharmacological treatment of osteoarthritis, in 2011, by the University of Toronto, Women's College Research Institute, found that these therapies, consisting of acupuncture, herbal and nutrient medicines, were difficult to assess due to study design, but that many of these therapies showed significant benefit over placebo and no intervention (waiting list). It will be some time before the system allows clear acknowledgement of benefit in studies when these relatively inexpensive and non-patentable therapies present such monetary considerations versus standard care in the industry, and studies like these imply such. Public demand, as well as a change to an outcome-based monetary system in healthcare will insure that integration of safe, effective and inexpensive treatments are finally acknowledged: http://www.ncbi.nlm.nih.gov/pubmed/21324369
  20. Studies in 2010, reviewed by the Case Western Reserve University School of Medicine in Cleveland, Ohio, finds that a number of proinflammatory cytokines disrupt the metabolism of joint tissues in osteoarthritis and may compromise and play a part in the inadequate repair of the cartilage. http://www.ncbi.nlm.nih.gov/pubmed/20104937
  21. A study in 2012, at Thammasat University, Pathumthani, Thailand, studied the effects in a randomized controlled human clinical trial of combining curcumin extract (from the Chinese herbs E zhu, Yu jin, or Jiang huang), a potent herbal anti-inflammatory that inhibits COX-2, TNF-alpha, IL-1, IL-8 and iNOS, with standard NSAIDS to see if the outcomes were improved, or if the dosage of the NSAIDS could be reduced. The trial showed that adding curcumin to the NSAIDS protocol produced better pain and functional outcomes than the NSAIDS with placebo, but the outcome differences were not dramatic. Since this study, though, research has revealed that standard curcumin extract comes with a limitation of the blood levels of curcumin allowed in the human organism, and optimized curcumin has been studied and produced to achieve higher circulating dosage, in the form of the patented LongVida optimized curcumin extract: http://www.ncbi.nlm.nih.gov/pubmed/23964444
  22. A review of scientific literature by researchers at the University of Montreal, Canada, in 2011, found that the exact causes of osteoarthritis still eludes scientific understanding, but that the inflammatory cytokines IL-1beta and TNFalpha appear to play a significant role, and anticytokine therapy, as demonstrated above in studies of Chinese herbs, has much potential in the overall treatment strategy. http://www.ncbi.nlm.nih.gov/pubmed/21119608
  23. Research is progressing on the study of an integrated holistic treatment protocol for osteoarthritis at Fujian University in Fuzhou, China, incorporating acupuncture, physiotherapy, pharmaceutical medications, functional training, intra-articular hyaluronic acid injections, and debridement with Chinese medicine inotophoresis therapy: http://www.ncbi.nlm.nih.gov/pubmed/20697952
  24. A consensus on the need for a multimodality integrated treatment protocol for osteoarthritis is developing since 2010. This review by researchers at the University of Michigan and Michigan State University examined the current proven treatment options, including acupuncture, physical therapies, nutraceuticals, topical ointments, hyaluronic acid injections, pulsed electrical stimulation, and pharmaceutical interventions: http://www.ncbi.nlm.nih.gov/pubmed/20631473
  25. A 2009 meta-analysis of well-conducted clinical studies, systematic reviews of scientific studies, and past meta-analyses conducted by the Center for Health Studies in Seattle, Washington, found that evidence supports acupuncture as an effective reasonable option for treatment of osteoarthritis, chronic back pain, and headache (although the reviewers bias against this therapy is evident in the wording of the review conclusions): http://www.ncbi.nlm.nih.gov/pubmed/20445762
  26. A 2011 study by the Chinese Academy of Medical Sciences in Beijing, China, found that acupuncture stimulation effectively down-regulated MMP-3 and MMP-1, and upregulated TIMP-1 (tissue inhibitor of metalloproteinase-1), explaining in part the physiology of how acupuncture stimulation at ST35 and ST36 could promote cartilage regrowth and cure osteoarthritis of the knee: http://www.ncbi.nlm.nih.gov/pubmed/21644313
  27. A 2009 meta-analysis of well-conducted clinical studies, systematic reviews of scientific studies, and past meta-analyses of herbal medicinals in the treatment of osteoarthritis conducted by Victoria University Centre for Aging, in Melbourne, Australia, found 35 sound placebo-controlled randomized human clinical trials, but excluded all but 3 because of reviewer disagreements. Nevertheless, the 3 studies of a Chinese herbal formula, topical capsaicin, and soybean isoflavones and lignans, found significant evidence of benefit, and reviewers admitted positive findings of moderate benefit in the other 32 studies as well. The consensus was that proof of benefit was not proven beyond doubt, but that the obvious potential benefits in reduced reliance on synthetic medications with considerable risks and side effects warranted the use of herbal medicines in standard protocol (once again, the bias of researchers against Complementary Medicine in standard research review is obvious). : http://www.ncbi.nlm.nih.gov/pubmed/20445762
  28. A 2004 study by the National Cancer Institute, Nutritional Sciences Research Group, in Rockville, Maryland, outlines the key nutrients that may restore the deficient epigenetic DNA methylation found in osteoarthritis patients. Zinc monomethionine, 5MTHF (active folate), B12, B6, genistein phytosterol, methylselenocysteine, and Vitamin A all may play synergistic roles in restoration of DNA methylation: http://ebm.rsmjournals.com/content/229/10/988.full
  29. An excellent synopsis of the pathologies associated with alkaline phosphatase deficiency or excess is found at this website: http://www.drkaslow.com/html/alkaline_phosphatase.html
  30. A 1994 study at the University of California, San Francisco, showed how key inflammatory cytokines altered the production of parathyroid hormone-related protein (PTHrP), and integral component of the healthy regulation of cartilage to bone turnover in joint maintenance: http://www.drkaslow.com/html/alkaline_phosphatase.html
  31. A 2008 study in Denmark found that a review of many scientific studies confirmed that estrogens have a variety of direct and indirect effects in cartilage maintenance, playing a role in the balance of factors needed to maintain the complex homeostatic maintenance of cartilage and bone at the joints: http://www.ncbi.nlm.nih.gov/pubmed/18202960
  32. The Women's Health Initiative reported in 2006 that synthetic hormone replacement with progestins and estradiol showed a mild decrease in risk of osteoporotic bone fractures, but that the increased risk of breast cancer, ovarian cancer, heart attack, stroke, thromboses, Alzheimer's, and other dementias was significantly increased, thereby making this treatment strategy recommened only as a last resort: http://www.aolhealth.com/drugs/hormone-replacement-therapy-for-osteoporosis
  33. Study findings regarding the rate of osteoporotic bone loss from DepoProvera, a progestin, or progesterone derivative synthetic hormone contraceptive: http://www.nichd.nih.gov/news/releases/bone_loss.cfm
  34. Fosomax and other biphosphonate drugs used to treat osteoporotic bone loss now come with stern FDA warnings concerning risk of bone necrosis: http://www.adrugrecall.com/fosamax/fosamax.html
  35. 2008 FDA warnings concerning Fosamax, Actonel, Boniva, Zometa, and other biphosphonate drugs to treat osteoporotic bone loss were added to existing warnings. These new warnings concerned a high incidence of severe and sometime incapacitating pain resulting from use: http://www.fda.gov/cder/drug/infopage/bisphosphonates/default.htm
  36. U.S. clinical trials concluded in 2006 that even among relatively healthy postmenopausal women, that calcium and vitamin D supplementation had only a small improvement in hip bone density, did not significantly reduce hip fracture, and increased risk of kidney stones: http://content.nejm.org/cgi/content/abstract/354/7/669
  37. A large study of hormone Vitamin D3 deficiency at the Arthritis and Osteoporosis Centre of Victoria University Hospital in Cork, Ireland, found that 70% of women newly diagnosed with osteoarthritis and osteoporosis had hormone Vitamin D3 deficiency, and 26% had a severe deficiency. Imbalances of parathyroid hormone and alkaline phosphatase levels were also prevalent: http://www.ncbi.nlm.nih.gov/pubmed/21184246
  38. A 2009 study at the Shriners Hospital for Children in Quebec, Canada, found that not only systemic hormone Vitamin D3, but locally produced D3 in cartilage cell (chondroctyes) plays a significant role in repair and maintenance of cartilage and bone in osteoarthritis: http://www.ncbi.nlm.nih.gov/pubmed/19477943
  39. Calcium content in foods is listed on the UCSF Medical Center website: http://www.ucsfhealth.org/adult/edu/calciumContent/index.html
  40. Wikepedia has a reliable complete explanation of Vitamin D metabolism: http://en.wikipedia.org/wiki/Vitamin_D
  41. The National Institutes of Health reported findings of Vitamin D deficiency in a large percentage of our population in 2005: http://www.ncbi.nlm.nih.gov/pubmed/16315387
  42. The Linus Pauling Institute at Oregon State University provides a complete informational article on Vitamin D supplementation and information on which drugs may inhibit Vitamin D metabolism: http://lpi.oregonstate.edu/infocenter/vitamins/vitaminD/
  43. A study at the University of California San Francisco Clinical Research Center found that controlling acidic states with potassium bicarbonate improved calcium phosphorus balance, reduced bone resorption, and increased the rate of bone formation: http://content.nejm.org/cgi/content/abstract/330/25/1776?ijkey=a72aa7b9ae4bcb662db571778f11cc912870d579&keytype2=tf_ipsecsha
  44. Calcium bioavailability from calcium rich mineral water was found to be excellent: http://www.ajcn.org/cgi/content/abstract/62/6/1239?ijkey=d4a1265bdabf56b011eed6838c3fad6394776f27&keytype2=tf_ipsecsha.html
  45. Plant phytoestrogens have been found to exert significant dose-related effects on bone-related cytokines and PHTrP in this study in Spain in 2009: http://www.ncbi.nlm.nih.gov/pubmed/19632246