Joint Degeneration and Arthritis

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

Sections

Degeneration of the Knee joint and Cartilage

Degeneration of the knee joint may involve a variety of tissues. In most cases, the cartilage, or tissue covering the bone at the joint, is softened and degenerated, sometimes until parts of the cartilage are almost completely absent. In other cases, the joint meniscus, a fibrocartilaginous structure of the knee joint, with a crescent or horsehoe shape, is degenerated and experiences a number of small tissue tears. The ligaments of the knee, especially the interior ligaments, or cruciates, are also involved in many cases, causing joint laxity, and a knocking sound, or feel, of the bones with movement. Ligaments are fibrous tissues connecting and stabilizing two or more bones, and their cartilage, or other fascial tissues of the joints. While many patients associate tears of the ligaments and meniscus with injury, the majority of these cases do not involve trauma. While arthroscopic surgical repair has been the standard treatment for decades, more and more large clinical studies have shown that this often results in a temporary improvement, with degeneration continuing unless addressed with conservative physiotherapies, and for many patients with degenerative tissue tears and loss of healthy cartilage, a conservative protocol with physiotherapies, including acupuncture and Tui na, enhanced with herbal and nutrient medicine, targeted stretch and exercise, will provide a better outcome even without surgical repair.

A large randomized controlled human clinical trial in Finland, in 2013, showed that the outcomes were identical for patients receiving arthroscopic surgery to repair meniscus tears in degenerative knee joint without advanced osteoarthritis, and for the patients receiving a sham surgery with a small visible incision (see the study cited below in Additional Information). This finally proved that conservative care and rehabilitation of the joint tissues with healthy regrowth is needed, not just arthroscopic surgery. While many patients may interpret this RCT as a denial of the benefits of arthroscopic surgery, this is not the case. What is really revealed is proof that soft tissue physiotherapy and rehabilitation work. The surgeons and patients should be more selective with arthroscopic surgery, and integrate these conservative therapies, whether or not surgical repair is chosen, especially Complementary and Integrative Medicine.

To utilize Complementary and Integrative Medicine (CIM) in promoting repair and healthy regrowth of tissues in the knee, the patients and physicians need to understand the mechanism of degeneration and formulate a sensible treatment protocol to achieve healthy repair and regrowth. The combination of acupuncture, electroacupuncture, soft tissue mobilization, targeted stretch and exercise, correction of body mechanics, and herbal and nutrient medicine provide a comprehensive package of care that can be obtained in short courses of therapy from a knowledgeable Licensed Acupuncturist with training in Tui na. For many patients, chronic pain is the most important consideration leading to a choice of arthroscopic surgery with degenerative knee conditions, but a 2015 meta-review of studies by the University of Southern Denmark and the University of Lund, in Sweden, published in the esteemed British Medical Journal (BMJ), concluded that while these arthroscopic surgeries for older patients with degenerative knees achieve a small benefit in pain relief for 6 months, that long term pain relief was not evident (see study link in Additional Information). While standard medicine is now promoting a notion that the patient might just wait until the knee is fully degenerated and opt for a prosthetic knee, a more sensible evaluation would conclude that there is a vast need for conservative care that can help restore the knee tissues and reverse degeneration. Even if the arthroscopic surgery for knee pain with degeneration or without degeneration is adopted, the integration of Complementary Medicine and conservative therapies with acupuncture, physiotherapy, and herbal nutrient medicine is obviously needed.

For many years, it was assumed that "wear and tear" was primarily responsible for these tissues experiencing degeneration. In the knee, there are two areas with cartilage, or bony covering, namely, the cartilage of the primary bones (femur, tibia and fibula), and the cartilage of the moving kneecap (patella). The degeneration of the patellar cartilage is still referred to as "runner's knee", revealing the past prevalent notion that most cases were due to mechanical wearing down of the cartilage. The actual term is chondromalacia patella, implying that insufficient circulation of nutrients is mainly responsible for the degeneration of the patellar cartilage, with wear and tear merely contributing. Degeneration of the cartilage of the primary bones is mainly due to osteoarthritic changes, and this has a more multifactorial cause. A combination of poor tissue nutrient delivery (malacia), improper mechanical stresses, inflammatory dysfunction, and hormonal changes are believed to be the main underlying factors contributing to osteoarthritic degeneration of the cartilage of the primary bones of the knee. Obviously, a thorough and holistic approach to treatment is needed to address these factors, as well as a time intensive and individualized approach. Standard medicine does not deliver this type of treatment approach, but integration of the more cost effective and time intensive treatments in Complementary Medicine could fulfill this need. The specialty of the Traditional Chinese Medicine (TCM) includes physiotherapies (Tui na), herbal and nutrient chemistry, acupuncture and electrical stimulation, and patient instruction in therapeutic regimens and correction of postural mechanics.

In 2014, many clinics opened in the United States touting the promise of stem cell therapy to regrow degenerative cartilage, but the FDA had little oversight and regulation of this protocol, relying mainly on regulatory laws that required safe manufacturing processes for the stem cells, much like the poor regulation of medical devices. In response to quickly expanding use of stem cell research the FDA moved to announce plans to regulate stem cell therapy as it does Biologics, as most of the new stem cell protocols actually were changing the stem cells more than minimally, in effect making these stem cells a "biologic drug". The long-term risks included the potential for stem cells that did not turn into cartilage cells to multiply and mutate, creating a new type of cancer. A 2014 review of this therapy, by experts at the Saarland University School of Medicine, in Homburg, Germany, noted that while initial use of mesenchymal stem cells showed some encouraging results for treating focal lesions, no evidence of the therapy resulting in a restoration of fully functional cartilage surface has been produced. These experts cite the need to integrate 'biological supplements' in a more holistic treatment protocol. To see this review, just click here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3897321/ . While use of these mesenchymal stem cells for focal cartilage lesions in professional athletes, who have a very comprehensive and holistic treatment protocol available, has shown success, normal patients should be wary of claims that this protocol alone will fix their problem. Many experts in the field believe that we are in a stage of human experimentation due to the lack of FDA regulation, and that only when we truly determine how to minimize long-term adverse outcomes should we rely on this new technology. The promise is there, but not the assurance of safety and long-term success. We also do not know whether tissue grown with stem cell transplants will be well regulated by the body, or whether the various factors causing the degeneration will result in the return of the condition after an initial period of success. No matter what the patient chooses, integrating a more holistic protocol will insure better long-term outcomes.

The study of cartilage degeneration has revealed much about the disease mechanisms, and thus much about the needed treatment protocol, which must address a variety of factors. This study of cartilage degeneration, or osteoarthritic changes, is not new. For instance, a study from 1969, at the Institute of Orthopaedics at the University of London, and the Royal National Orothopaedic Hospital in Stanmore, Middlesex, UK, by S.Y. Ali and Lois Evans, revealed that degenerative cartilaginous diseases showed a loss of protein-polysaccharide (glycoprotein) component and fall in the production of chondroitin sulphate. The deficiency of the cartilage cells, or chondrocytes, in the production of condroitin was related to the glycoprotein changes. These glycoprotein changes were correlated with increased enzyme activities stimulated by chronic inflammation in the surrounding tissues. Acidity changes also stimulate enzymatic tissue degradation in the cartilage, with a maximum breakdown of cartilage and glycoprotein at pH5, with a release of over 50 percent of the chrondromucoprotein content quickly. Acidity levels are highly correlated with enzyme activity rates. Cathepsins, or protease enzymes, in the cartilage cells were thought responsible for this loss of glucosamine and chondroitin. These proteolytic enzymes called protease cathepsin break down other proteins. A balance of cathepsins is needed to maintain tissue homeostasis, and imbalance of inflammatory processors, and mediators, as well as chronic acidic states, lies at the heart of cartilage degeneration. Eventually, glucosamine and chondroitin supplements were recommended, but taking these orally have limited effect. Chemicals to inhibit cathepsins would be problematic, as these protease enzymes also regulate many important and beneficial processes in the body, preventing amyloid plaques in Alzheimer's disease, the spread of some cancers, denervation in diseases such as multiple sclerosis, etc.

To aid restoration of the cathepsin protease metabolism and stop the cartilage degeneration, a number of therapeutic aids should be used. Regulation of inflammatory processes should be paramount, then clearing of diseased and dysfunctional tissues with antioxidants and proteolytic enzymes, and finally the supply of depleted proteins, such as DL-phenylalanine, L-arginine, L-leucine, and L-glutamine. In studies, the hydrolysis of the chymotrypsin substrate benzoyl-DL-phenylalanine 2-naphthyl ester accounted for much of the breakdown of cartilage at pH5 (slightly acidic), with an imbalance of the cathepsins A and B. Supplementation with DL-phenylalanine may thus be an important constituent of therapy, and may also prevent the excessive breakdown, or catabolism, of endorphins, the important opioid neurotransmitters that facilitate pain relief. Warnings that daily doses of DL-phenylalanine of over 5000 mg daily may be toxic and contribute to nerve damage were widely reported after the studies of positive effects, but since a single dose is only 500 mg, this warning may be meaningless. These amino acids may be found in whey protein supplement, taken individually, or found in foods. Phenylalanine is found in many seeds and beans, bean sprouts, watercress, and acacia. Phenylalanine and L-Tyrosine are commonly used as supplements to supply an improved bioavailability of dopamine and epinephrine, perhaps benefitting mood and brain function. Cathepsin D was also shown to have a potent proteolytic activity involved in the cartilage breakdown. This enzyme uses aspartate and is more active at acidic pH. Aspartic endopeptidases are also seen in fungal and retroviral microbes, and potentially could link systemic problems with Candidiasis, as well as retroviral infections of a low-grade, to cartilage degeneration. Many studies show links between ill health of the intestines and the so-called "leaky gut" syndrome to chronic joint pain and degeneration. Such study links improved gastrointestinal function to improved status in arthritic conditions. While this scenario is complex, and is different from one patient to the next, the evidence does point us in the direction we must take to reverse joint degeneration. It appears that scientific study indicated a need for a holistic protocol long ago, but this was largely ignored. Restoration of cartilage and reversal of this degenerative process is possible, but success is unlikely unless a thorough, thoughtful, and holistic treatment protocol is applied.

Often, a combination of destructive and productive changes occur in joint arthropathies, and when the destructive activity exceeds the productive restoration, an eventual degeneration of the joint occurs. The key to treatment is early recognition of this condition, and an array of therapeutic steps taken to decrease the destructive changes and increase the productive.

Erosive arthritis is the prototype of this type of arthritis, and an array of problems may contribute to destructive degeneration of tissues, such as episodic bursitis, gout, pseudogout calcification, patellar tracking syndromes, and altered biomechanics. Often, myofascial syndromes contribute to altered biomechanics, and a simple correction of chronic myofascial stress imbalances will do much to correct this destructive mechanical force. Both correction of destructive forces and encouragement of circulation and productive mechanisms are needed to restore the healthy daily regrowth of joint tissues. Degenerative conditions of the joints occur when normal maintenance of the joint tissues is inadequate to counter mechanical stresses and/or inflammatory diseases. Side effects of medication may also play a significant role, as well as metabolic deficiencies. Many medications list joint pain as a significant side effect, such as cholesterol lowering statins, gastric acid inhibiting drugs, antibiotics, medications treating high blood pressure, biphosphonate drugs used to treat osteoporosis, etc. By the time joint pain becomes debilitating the degenerative process is already advanced. The patient must look at three approaches to this problem: 1) pain relief, 2) identification of the causes and contributors to the tissue degeneration and subsequent correction of these problems, and 3) restoration of healthy tissue and proper response of the inflammatory mechanisms to clear unhealthy tissues and replace them with new healthy growth. Most patients are only focused on pain relief, and this is a grave mistake, as palliative treatment alone will lead to a worsening of joint degeneration in many cases, and restoration of the joint homeostasis becomes more difficult in later stages.

In the recent past, standard medicine led the patients to believe that arthroscopic surgery would correct problems with degenerative knee joints. More recent evidence suggests that many arthroscopic knee surgeries to repair meniscus tears may be unwarranted, and that the problem will recur due to degenerative arthritic conditions if these problems are not addresssed in therapy. In a New York Times article in the Health section on December 8, 2008, Dr. David Felson, a professor of medicine and epidemiology at Boston University, explained a study of 991 people ages 50 to 90, some with knee pain and some without, that were examined with multiple MRI scans to determine the frequency and meaning of meniscal tears in the general population. The conclusions, published in the New England Journal of Medicine, were that meniscal tears were just as common in arthritic joints without pain as those that produced pain, and so repairing the joints surgically was not the answer to eliminating the pain. Dr. Felson found that 40 percent of the general population had meniscus tears at age 60, and there was little correlation between these tears and the pain. He believes that arthritis and chronic inflammatory degeneration are the cause of most knee pain in the aging population, and that conservative care should be utilized to correct this problem. TCM can deliver this conservative care.

In 2014, a meta-review of all studies of long-term outcomes with arthroscopic surgery for patients averaging 56 years of age with degenerative meniscus tears in the knees, at McMaster University, in Ontario, Canada, found that such surgery provided only temporary improvement function, but at 6 months or longer from surgery, there was no significant improvement in function or pain relief. Dr. Moin Kahn, the lead researcher on this meta-review of randomized controlled human clinical trials involving more than 800 patients, stated that these findings clearly indicate that chronic pain from a degenerative condition of the knee in a middle-aged person may not benefit from arthroscopic surgery in the long run, and that a more conservative and comprehensive treatment strategy should be integrated into care. He emphasized that this does not mean that an acute traumatic meniscus tear in a young adult should not utilize surgical repair, but a comprehensive and holistic protocol for aging degenerative knee conditions should be adopted. Traditional Chinese Medicine, with a protocol of acupuncture, physiotherapy, herbal and nutrient medicine, as well as instruction in targeted therapeutic stretch and exercise, provides such a protocol, and should be integrated with standard minimal use of anti-inflammatory medication when needed, as well as short courses of standard physical therapy. For too long standard medicine has been advising these patients to avoid this conservative care and instead opt for profitable arthroscopic surgery and chronic dependence on pain medication. We now have proof that this was the wrong advice and protocol.

Real restoration of the joint tissues depends on concurrent physiotherapy and use of aids to help the body with tissue regeneration. Once the patient learns to correct problems with body mechanics that continue to injure the joint, and corrects other problematic causes of tissue degeneration, such as chronic inflammatory states or diseases, tissue regeneration is possible, even with cartilage. Sometimes arthroscopic surgery is absolutely necessary to clean up dead tissue so that healthy tissue may grow, but the surgical assessment should consider the actual need and benefit realistically, and work in an integrated fashion with other health professionals to achieve regrowth of healthy tissues and take care of problems that contribute to chronic joint inflammation. Post surgical care should include passive mobilization, myofascial release, acupuncture, herbal medicine, and nutrient therapy to aid healthy repair and regrowth of the joint cartilage, ligaments and tendon attachments. Health concerns that contribute to arthritis, or poor inflammatory function, should be addressed holistically.

An Array of Less Invasive and Restorative Therapies are Introduced into Standard Medicine

"Modern medicine is turning to less invasive and more holistic protocols such as prolotherapy, laser surgery and other minimally invasive surgical techniques combined with a comprehensive package of support therapy to promote healthy restoration of the arthritic joint. Health authorities such as the Mayo Clinic state that therapies such as prolotherapy alone will not result in a healthy regrowth of cartilage and joint tissue. This is where the use of Complementary Medicine comes into play."

Prolotherapy is an example of the new attitude taken by the medical community to degenerative joint conditions. In this therapy, also called sclerotherapy, sugar or nutrient solutions are injected repeatedly into the deteriorated or degenerative ligaments, joint capsule soft tissues and tendon attachments to stimulate regrowth of the fascia, or connective tissue. Prolotherapy produces an inflammatory response in these soft tissues to stimulate regrowth, but as the Mayo Clinic reports on their website, prolotherapy alone is not proven to be beneficial. It must be combined with an array of Complementary therapies to achieve success. Since prolotherapy injections are performed every 3-6 weeks during the course, integrating this array of complementary therapies is not a problem. Utilizing acupuncture, topical herbal medicines, and nutrient medicines, all of which have shown clinical proof of benefit to arthritic joint conditions, along with direct soft tissue physiotherapies, such as TuiNa and myofascial release, the ultimate success with prolotherapy is greatly enhanced. Therapies such as prolotherapy and arthroscopic surgical repair may be utilized by the patient with advanced joint degeneration, but it would be a big mistake to assume that these interventions alone will restore joint health. If the underlying mechanisms that led to joint degeneration are not addressed, the same joint degeneration will recur.

Prolotherapy produces an inflammatory response in the joint tissues to promote healthy growth, and we can understand from this approach the necessity of improving the inflammatory functions in the body. While anti-inflammatory medicines such as ibuprofen and naprosen may relieve pain temporarily, the inhibition of inflammatory processes may result in long term degeneration rather than healthy tissue restoration. Corticosteroid injections, which may promote the inflammatory process and modulate it temporarily, will also cause joint degeneration if repeated too often, and a new clinical trial comparing long-term outcomes of PRP (platelet-rich plasma injection) and corticosteroid injection showed that corticosteroids provided no improvement in long-term outcomes of pain and disability (see NY Times article cited below). Corticosteroids come with considerable health risk when a patient is taking multiple products with synthetic steroids chronically, and synthetic steroids are now found in many prescription and over-the-counter products. The real benefit of corticosteroid injection is a short-term relief of pain that provides a window of opportunity for the patient to utilize an array of conservative treatments to achieve better tissue healing. Complementary and Integrative Medicine provides this array of treatments, combining phyisotherapies with acupuncture, herbal medicine, topical herbs, nutrient medicine, and patient instruction to ahcieve maximum results. Complementary Medicine also utilizes the inflammatory mechanism to do what it is supposed to do, not just create pain, but to repair the tissue. Herbal and nutrient medicine may optimize the inflammatory response to promote the natural tissue healing mechanisms built into the body. For this to work a comprehensive and holistic approach must be taken that insures that your immune response and inflammatory tissue repair works optimally.

One type of injection that has been utilized more frequently in recent years for degenerative joints, especially for osteoarthritic knee joints, is hyaluronic acid. A multicenter placebo-controlled trial of the effects of this therapy in France was completed in 2008, and the results indicated that a single injection of hyaluronic acid produced no better results than placebo (see additional information below). Hyaluronic acid is a substance found in normal joint fluid and tissue, and is a major component of synovial fluid, which lubricates and protects the white tissues of the joints. While a single injection of hyaluronic acid proved ineffective, probably because tissue receptors for hyaluronic acid limit the cellular intake from a large dose, repeated topical use of a small amount of hyaluronic acid has proven beneficial for some dry joint tissues, especially if administered with a carrier substance. Research is also progressing on the effects of a small amount of pure hyaluronic acid take sublingually and distributed to receptors via blood circulation. This is just one facet of a comprehensive package of therapy that may be needed to achieve healthy repair and regrowth of the degenerated joint tissues. By studying this article, the patient with joint degeneration can gain understanding of the best therapeutic aids in Complementary Medicine and combine these into an effective package of care.

A third type of injection involves platelet-rich blood plasma (PRP), which theoretically releases growth factors and nutrients to speed the growth of healthy joint tissues. This therapy has faced much criticism, though. A 2010 article in the New York Times, entitled Popular Blood Therapy May Not Work, reports that the editor of The American Journal of Sports Medicine, Dr. Bruce Reider, describes this procedure as "platelet-rich panacea", and the head researcher at Hague Medical Center in the Netherlands, who performed the first extensive rigorous study of effects, reported that the injections performed no better than the salt water placebo used in the randomized clinical trial. Dr. Johannes Tol stated: "We are sorry for the patients, there is still no good treatment (for cartilage degeneration)." The PRP injections are still being used to treat degenerative knees in sports medicine, but are not paid for by the insurer. A rigorous protocol of physiotherapy and other conservative treatments is always used in these cases of high profile athletes receiving PRP, though, and if a patient chooses to pay for this therapy, integrating the physiotherapy, acupuncture stimulation, herbal and nutrient medicines that are backed by sound research would seem sensible.

Much research has been funded to explore improved methods for microfracture, platelet-rich plasma injection, injection of bone marrow derived chondrocyte stem cells, and use of oxidized zirconium implants, as well as human cartilage implants, to effectively treat focal cartilage defects that cause joint pain and instability. Unfortunately, while these procedures are effective for very small advanced cartilage lesions, the expense, time for recovery, and adverse effects on the degeneration of the surrounding cartilage have presented considerable drawbacks. When these new techniques for focal cartilage regeneration are utilized, there is a tremendous need for a comprehensive package of rehabilitative protocols following the procedure. Here too, integration of Complementary Medicine makes much sense in achieving the best possible outcome. Refined research is identifying where in the body each of these new techniques is working the best, and hopefully, patients will explore this research and utilize surgeons and clinics that individualize these treatments, as well as integrate Complementary Medicine into the whole package of care.

A Total Package of Care to Restore Degenerative Joints Must Incorporate Direct Soft Tissue Mobilization and Nutrient Aids

"No single supplement or herb will work to achieve eventual repair and regrowth of healthy joint tissues when degenerative joint conditions and osteoarthritis or chondromalacia occurs. A package of care includes a combination of research-based medicines along with sensible physiotherapies, correction of body mechanics, and stimulation of both the joint and the systems in the body responsible for tissue maintenance and regrowth."

Joint tissues have no direct significant blood supply, and thus depend upon movement to push fluids in and out of these tissues. The white tissues are the cartilage, meniscus, ligaments and tendons, and these are the tissues that degenerate in the joint. One reason that they degenerate so severely in osteoarthritis is because the bone covering, or periosteum, which does have abundant blood and lymphatic vessels, is absent where cartilage covers the bone at the joint. Instead we normally have layers of cartilage where bone meets bone, and these layers are supplied with nutrients from two directions, the vascularized muscles, and the vascularized bone. When degeneration occurs in the bone and cartilage, spurs or osteophytes, and changes in the bone underlying the cartilage, occur, where this outer bone is converted into a dense smooth ivory-like substance (eburnation), preventing the lower layers of cartilage from getting the necessary blood supply from the richly vascularized bone and also preventing the normal conversion of cartilage into new healthy bone. This basement layer of your cartilage is composed of a type of cartilage cell that creates hyaline and type II collagen. This layer of cartilage near the bone is normally oxygen-rich, from the bone blood supply, and a lack of oxygen accounts for poor hyaline formation. Injection of hyaluronic acid alone will not correct this problem, and only restoration of these cartilage cells that produce hyaline will achieve proper lubrication and decrease of pain.

Cartilage is constantly growing and being replaced in the body, although this regrowth is slower than most tissues due to a lack of intrinsic blood nutrient supply. When degeneration of the cartilage exceeds the regrowth, the thickness decreases and eventually leaves the bone unprotected at the articular surface. Regrowth is obviously possible, and to regenerate cartilage this regrowth needs help. Hyaline cartilage is composed of 4 distinct layers, with the superficial layer softer and the less dense, but with a much greater collagen content. The superficial layer is believed to be the first to degenerate, and many experts now believe that this is because the hard calcified cartilage layer near the bone does not turn into bone fast enough. The cartilage cells, or chondrocytes, change in form and function from the superficial to the deepest layer, from a less dense elongated form that secretes little proteglycan, to rounded chondrocytes arranged in columns alongside thicker collagen fibers. Restoration of normal homeostatic changes in these cartilage layers is the key to rebuilding cartilage, and this requires a holistic protocol. A step-by-step therapeutic approach is necessary to regain the healthy metabolism of lubricating hyaline and formation of new collagen. A combination of passive joint mobilization, stimulation with acupuncture and electrical stimulation, increased blood flow, healthier immune reaction, antioxidant clearing, and tissue nourishment with type II collagen, and perhaps hyaluronic acid included in the comprehensive treatment protocol, is the logical course to increase the success of this therapy.

Collagen type II is the main rebuilding material for both joint tissues and bone, and when a repair and regrowth is stimulated with a package of proper therapy, an enormous amount of this material is needed by the body. Unfortunately, for many patients with degenerative conditions, not enough collagen type II is produced by their cells. The subject of delivery of exogenous collagen type II to the patient has been studied for some time. Initially, it was hoped that glucosamine sulfate and chondroitin could be take orally and provide a better production of collagen type II and joint tissue regrowth. Unfortunately, taking these supplements orally has little effect at the joint because the digestive process breaks down these substances before they reach the joint in the blood circulation. Research at Harvard University has progressed to the completion of two human clinical trials utilizing purified extracts of bioidentical collagen type II from chicken tissues. Methods of extraction, purification, and now encapsulation with an eggshell glycoprotein, has produced a type of collagen type II that can be taken orally and is proven to reach the affected joints. Utilizing a health professional, and dependable professional products such as these, is very important to the success in therapy. When utilizing this research-based nutrient, it would be more effective when the joint is receiving proper physiotherapy and stimulation, when the patient is progressing with targeted stretch and exercise, and when other research-based herbs and supplements are used to promote circulation, tissue repair, and antioxidant clearing. One potent antioxidant is derived from pomegranate, not just the juice, but the inedible parts of the plant also, which contain potent OPCs that have been proven to also modulate the immune response that drives osteoarthritic degeneration, with excess of interleuin-1.

Unhealthy collagen may also be a problem in chronic joint pathologies and degeneration. It has been demonstrated in studies that advanced glycation endproducts (AGEs) may cause oxidative stress and stiffened collagen cross-links that are problematic for both joint tissues and bone. In autoimmune reactions, such as Rheumatoid arthritis, unhealthy collagen may be an important trigger of autoimmune reactivity. The Harvard studies of collagen extracts have proven in clinical human trials that this patented form of collagen supplement significantly replaces unhealthy collagen in both Rheumatoid arthritis and osteoarthritis patients. Decrease of AGEs and AGE receptors may also significantly improve chronic arthritic degeneration. Since the glycation Maillard reactions in collagen and vascular endothelium may occur on protein residues, effective proteolytic enzymes may also be useful in the overall protocol. These problems with AGEs and poor tissue quality are especially suspect in patients with metbolic syndrome (insulin resistance or Diabetes type 2), but are also noted as a physiological problem associated with normal aging. Measurement of increased urinary excretion of key AGEs, such as pentosidine, have been highly associated with osteoporotic vertebral microfractures in studies as well. These bone degenerative conditions may be an important part of the pathology in chronic lumbar joint degeneration and subsequent arthritic conditions.

Not only the white tissues of the joint, capsule, ligament and tendon, but also the bone covering, or cartilage will need to repair and regrow. More advanced study of the physiology of this cartilage near the bone has indicated that activated Vitamin D3 hormone, or 24,25-(OH2) D3, is essential to regulation of the healthy calcification of this layer of cartilage. When calcification slows, the cartilage near the bone becomes hypertrophied, or swollen, preventing both circulation to the tissue, as well as inhibiting the growth mechanism of the more surface layers of cartilage. Restoration of this D3 hormone mechanism involves more than just taking Vitamin D. Hormone balance is essential to the Vitamin D3 metabolism. Restoration of healthy hormone balance may thus be needed in certain patients with degenerative cartilage. In the healthy individual, most of our Vitamin D3 cholecalciferol prohormone is generated in our skin with frequent exposure to sunlight for short periods at midday. This cholecalciferol is then transformed, via a number of enzymatic steps, tightly controlled by endocrine feedback regulation, into the activated hormone D3 forms that we need. This occurs mainly in the kidneys, and herbal formulas designated as kidney tonics in TCM have been traditionally used to help restore cartilage and degenerative joints, especially knees. To restore potential hormone Vitamin D3 deficencies that may be greatly contributing to your degenerative cartilage and joint conditions, a thorough holistic approach is recommended, and professional guidance may be necessary. The book entitled Cartilage, by Brian Keith Hall and Stuart A. Newman thoroughly outlines these findings, and states: "What distinguishes chondrocytes (cartilage cells) of the growth plate from other chondrocytes would appear to be their ability to respond to environmental regulation by Vitamin D metabolites in a manner not shared by other chondrocytes." What this means is that for patients with chronic degenerative cartilage, no matter what the cause, surgical correction and supply with nutrients such as glucosamine and chondroitin will not achieve ultimate goals of restoration without a healthier hormonal support. This type of increased hormonal health can only be achieved with a holistic approach.

Stimulation of Growth and Correction of Impediments to Healthy Tissue Growth Are Also Needed

A second type of joint degeneration occurs with repetitive wear and tear to the upper layer of cartilage, and this is called chondromalacia, or commonly 'runner's knee'. In this degenerative condition, the upper layers of cartilage, usually under the patella, degenerate due to poor regrowth when patellar motion wears away the surface of the underlying cartilage. Uneven muscle tension and/or joint subluxation may be the cause of this abnormal abrasion of the patella against the cartilage. Most cases occur in young athletic individuals, especially women, whose wider pelvic structure may create more lateral force on the patella. Masking of the pain with non-steroidal anti-inflammatories and steroid injections may actually contribute to the degeneration because these allow the athlete to continue with harmful activities instead of resting and affecting repair. Using conservative therapies early in the syndrome may be the best advice one could get. After the chondromalacia has become chronic, there are few standard treatment options. Surgical correction has produced very few good outcomes, and often the patient is told that they may have to endure chronic pain until a full knee replacement is justified later in life. The patient wants to hear a more optimistic treatment plan than this. Since our body's tissues constantly regenerate, there is never a reason to believe that with proper treatment protocol, that restoration of healthy cartilage surface cannot by achieved. It only takes work, time, and the care of a knowledgeable Complementary Med physician who combines the various treatment strategies in a logical manner.

No matter what type of cartilage degeneration has occurred, whether due to aging and hormonal imbalance coupled with malnourished tissues, or primarily due to wear and tear, we do know that promotion of regeneration involves neovascularization and growth factors. VEGF, or protein vascular endothelial growth factor, is one of the most important factors in stimulating this regeneration. A 1999 study at the Department of Cardiovascular Research of Genentech, in San Francisco, California, coupled with research at the University of California San Francisco (UCSF) (Han-Peter Gerber et al; Nature Medicine(5): 623-628), found that angiogenic VEGF, when chemically blocked, resulted in degeneration of the cartilage and impairment of trabecular bone formation, with unhealthy hypertrophy of unhealthy tissue around the bone. The researchers found that "VEGF-mediated capillary invasion is an essential signal that regulates growth plate morphogenesis and and triggers cartilage remodeling." Promotion of VEGF and regulation of the factors that inhibit VEGF function, such as inflammatory and oxidant stress, are thus very important to regrowth of healthy cartilage. Research is exploring the effects of Chinese herbs, electroacupuncture stimulation, recombinant plasmid VEGF, and manipulation of blood proteins (PRP) that can be injected into the area of cartilage degeneration to promote VEGF and cartilage growth. Research in China is exploring the combination of recombinant gene therapy, herbal medicine and electroacupuncture to achieve these goals, and this has shown success. Integrative Medicine may play an important role in achieving better results in the difficult arena of cartilage regeneration in the future. For a large percentage of patients with osteoarthritic joint degeneration, hormonal imbalance and deficiency is a significant causal factor, and research in China, at Sichuan University, has shown that electroacupuncture can increase serum estrogen levels and decrease MMP-13 for these women as well, adding to the array of benefits (PMID: 23519019).

Clearly, modern medicine has demonstrated that mechanical stimulation of the articular joint cartilage is important in joint repair with degeneration. A number of techniques now use microfracture and other types of surgical abrasion to stimulate regrowth. What this also indicates is that traditional tissue and joint mobilization is an important consideration in the treatment protocol. A growing interest in this therapy, called Tui na in Traditional Chinese Medicine (TCM), which translates as soft tissue mobilization, and which is also now called Naprapathy, Osteopathy, etc. in other fields as well, has been backed by significant research demonstrating its effectiveness. Professionally applied mechanical stress therapies are proven to regulate the cell functions and stimulate growth, even of cartilage. Integrins are cell signaling molecules that coordinate this maintenance and regrowth, and act to bind and utilize collagens, fibronectin, cadherins selectins, and cel adhesion molecules, and soft tissue mobilization is proven to stimulate and modulate the expression of integrins to achieve faster cartilage regeneration. Such passive mobilization not only stimulates chondrocyte function (cartilage cells), and regrowth, but also improves circulation, gently breaks tissue adhesions and scarring that inhibit growth, and helps move calcifications out of the tissues.

Current trends in the U.S. are limited to advanced surgical techniques, such as microfracture, laser chondroplasty, grafting and cartilage plugs, and thermal chondroplasty. Unfortunately, these abrasive techniques stimulate the growth of fibrocartilage, not articular cartilage, leaving the patient with a prolonged process of regenerating actual smooth cartilage over the fibrocartilage. This long rehabilitative process lasts from 6 months to 2 years, and the fibrocartilage allows light use of the joint without symptoms, but with increased load bearing and heavier use, pain and swelling are expected. Current study shows that about 20-30 percent of patients do not recover full use of the joint after these procedures, even at 2 years. A comprehensive package of care, integrating Complementary Medicine intelligently, is needed, even when these procedures are utilized. Maintaining movement of fluids in and out of the regenerating cartilage, good circulation, myofascial release to decrease mechanical stress, and a potential for rebuilding not only the chrondrocytes, but the extra-cellular matrix, is extremely important. A narrow focus is a ticket for failure.