History and physical examination

All arthritides feature pain. Pain patterns may differ depending on the arthritides and the
location. Rheumatoid arthritis is generally worse in the morning and associated with stiffness; in
the early stages, patients often have no symptoms after a morning shower. In the aged and
children, pain might not be the main presenting feature; the aged patient simply moves less, the
infantile patient refuses to use the affected limb.

Elements of the history of the disorder guide diagnosis. Important features are speed and time of
onset, pattern of joint involvement, symmetry of symptoms, early morning stiffness, tenderness,
gelling or locking with inactivity, aggravating and relieving factors, and other systemic
symptoms. Physical examination may confirm the diagnosis, or may indicate systemic disease.
Radiographs are often used to follow progression or assess severity in a more quantitative
manner.

While evidence of primary ankle (kaki) osteoarthritis has been discovered in dinosaurs, the first
known traces of human arthritis date back as far as 4500 BC. In early reports, arthritis was
frequently referred to as the most common ailment of prehistoric peoples.[3] It was noted in
skeletal remains of Native Americans found in Tennessee and parts of what is now Olathe,
Kansas. Evidence of arthritis has been found throughout history, from Ötzi, a mummy (circa
3000 BC) found along the border of modern Italy and Austria, to the Egyptian mummies circa
2590 BC [4]

In 1715 William Musgrave published the second edition of his most important medical work De
arthritide symptomatica which concerned arthritis and its effects.[5]

Blood tests and X-rays of the affected joints often are performed to make the diagnosis.
Screening blood tests are indicated if certain arthritides are suspected. These might include:
rheumatoid factor, antinuclear factor (ANF), extractable nuclear antigen, and specific antibodies.

Rheumatoid Arthritis

Rheumatoid arthritis is a disorder where, for some unknown reason, the body's own immune
system starts to attack body tissues. The attack is not only directed at the joint but to many other
parts of the body. In rheumatoid arthritis, most damage occurs to the joint lining and cartilage
which eventually results in erosion of two opposing bones. Rheumatoid arthritis affects joints in
the fingers, wrists, knees and elbows. The disease is symmetrical and leads to severe deformity
in a few years. Rheumatoid arthritis occurs mostly in people aged 20 and above. In children, the
disorder can present with a skin rash, fever, pain, disability, and limitations in daily activities. No
one knows why rheumatoid arthritis occurs and all treatments are focused on easing the
symptoms. With earlier diagnosis and aggressive treatment, many individuals can lead a decent
quality of life. The drugs to treat rheumatoid arthritis range from corticosteroids to monoclonal
antibodies given intravenously. The latest drugs like Remicade can significantly improve quality
of life in the short term. In rare cases, surgery may be required to replace joints but there is no
cure for the illness. [10]
Rheumatic fever has now seen resurgence in America primarily because of mass immigration of
people from developing countries. The disorder can present with a migratory nature of arthritis
with many other features like heart problems, skin rash, gait abnormality and skin nodules.

Osteoarthritis

Unlike rheumatoid arthritis, osteoarthritis affects larger joints of the body, like the back, hip or
knee. The disease is essentially one acquired from daily wear and tear of the joint. Osteoarthritis
begins in the cartilage and eventually leads to the two opposing bones eroding into each other.
Initially, the condition starts with minor pain while walking but soon the pain can be continuous
and even occur at night. The pain can be debilitating and prevent one from doing any type of
activity. Osteoarthritis typically affects the weight bearing joints like the back, spine and pelvis.
Unlike rheumatoid arthritis, osteoarthritis is a disease of the elderly. More than 30 percent of
females have some degree of osteoarthritis by age 65.

Risk factors for osteoarthritis:

 Prior joint trauma

 Obesity
 Repetitive joint use
 Sedentary lifestyle

Osteoarthritis, like rheumatoid arthritis, cannot be cured but one can prevent the condition from
worsening. Weight loss is the key to improving symptoms and preventing progression. Physical
therapy to strengthen muscles and joints is very helpful. Pain medications are widely required by
individuals with osteoarthritis. When the disease is far advanced the pain the continuous, surgery
may be an option. Unlike rheumatoid arthritis, joint replacement does help many individuals
with osteoarthritis. [11]

[edit] Gout

It is caused by deposition of uric acid crystals in the joint, causing inflammation. There is also an
uncommon form of gout caused by the formation of rhomboid crystals of calcium
pyrophosphate. This gout is known as pseudogout. In the early stages, the gouty arthritis usually
occur in one joint, but with time, it can occur in many joints and be quite crippling. The joints in
gout can often become swollen and lose function. [13]

Prevention
While neither Rheumatoid arthritis nor osteoarthritis can be completely prevented, one can
reduce the risks by becoming physically active, participating in physical therapy, losing weight
and eating healthy. All individuals who have pain in the joints should seek early diagnosis
because the earlier the treatment is started, the better is the prognosis.

Treatment
Once the diagnosis of arthritis is made, treatments are available for a variety of symptoms. There
is no cure for either rheumatoid or osteoarthritis. The available medications can help reduce
inflammation in the joint which decreases pain. Moreover, by decreasing inflammation, the joint
damage is slowed. [17]

Treatment options vary depending on the type of arthritis and include physical therapy, lifestyle
changes (including exercise and weight control), orthopedic bracing, medications, and dietary
supplements (symptomatic or targeted at the disease process causing the arthritis). Arthroplasty
(joint replacement surgery) may be required in eroding forms of arthritis.

In general, studies have shown that physical exercise of the affected joint can have noticeable
improvement in terms of long-term pain relief. Furthermore, exercise of the arthritic joint is
encouraged to maintain the health of the particular joint and the overall body of the person.[18]

Medications
Physicians usually start with drugs which have the fewest side effects. As the arthritis progresses,
you may need stronger medications.[19]

Non-steroidal anti-inflammatory drugs (NSAIDs) are usually the drugs of first choice. These
drugs help decrease inflammation and reduce pain. Over the counter medications like Ibuprofen
or Aleve do help but most people require stronger prescription painkillers like Celebrex or
tramadol. While these drugs are effective, they are also associated with a variety of side effects
like abdominal pain, bleeding, ulcers, liver and kidney damage. Non steroidal anti inflammatory
drugs should not be used for prolonged periods without proper physician supervision.[20]

Corticosteroids are frequently prescribed for individuals with arthritis. These potent drugs can
help reduce inflammation and slow down joint damage. However, corticosteroids have potent
side effects which range from ulcer, skin bruising, weight gain, cataracts, bone thinning, diabetes
and hypertension. Corticosteroids are usually given for a short time to help reduce acute
symptoms.

Disease-modifying antirheumatic drugs (DMARDs) can help slow down progression of

rheumatoid arthritis and joint damage. The most common DMARDs include methotrexate
(Rheumatrex, Trexall), leflunomide (Arava), hydroxychloroquine (Plaquenil), sulfasalazine
(Azulfidine) and minocycline (Dynacin, Minocin). All these drugs have side effects which
include liver damage, bone marrow suppression and possibility of opportunistic infections.

Immunosuppressants like cyclosporine and cyclophosphamide suppress potent cells of the body
and help decrease the inflammation. These medications do help treat severe arthritis but also
make one prone to infections.

Tumor necrosis factor inhibitors have been shown to reduce inflammation, pain, morning
stiffness and swelling of joints. Drugs like etanercept (Enbrel), infliximab (Remicade) and
adalimumab (Humira) can significantly improve quality of life. The most common side effects
from these drugs include pain at site of injection, heart failure and increased risk of infection.[21]
Physical Therapy
Individuals with arthritis can definitely benefit from both physical and occupational therapy. In
arthritis the joints become stiff and the range of movements is limited. Physical therapy can teach
you how to relax the stiff joint and not damage the joint. Moreover, physical therapy can provide
splints or braces for your joints. There are also assist devices available that can help you drive,
getting a bath, dressing and also in housekeeping labors. Occupation therapy can teach you how
to reduce stress on your joint from daily living activities. Occupation therapy can also teach you
how to modify your home and work environment so that you do reduce movements that may
worsen your arthritis.

Physical therapy also involves use of ice, heating pads as well as ultrasound guided massage
therapy. Physical therapy for arthritis can be learned and practiced at home. To help reduce stress
on the joint, you will be taught how to distribute weight on the weight bearing joints. Other
aspects of physical therapy means learning how to maintain good posture, conserving energy by
allowing rest before and after activity.

Occupational therapy can help you do everyday activities without worsening pain or causing
joint damage. The techniques can help you distribute pressures to minimize stress on any one
joint. Ways to accomplish daily living tasks are made easier.

Osteoarthritis (OA, also known as degenerative arthritis or degenerative joint

disease), is a group of diseases and mechanical abnormalities involving degradation of joints,[1]
including articular cartilage and the subchondral bone next to it. Clinical manifestations of OA
may include joint pain, tenderness, stiffness, creaking, locking of joints, and sometimes local
inflammation. In OA, a variety of potential forces—hereditary, developmental, metabolic, and
mechanical—may initiate processes leading to loss of cartilage -- a strong protein matrix that
lubricates and cushions the joints. As the body struggles to contain ongoing damage, immune
and regrowth processes can accelerate damage.[2] When bone surfaces become less well protected
by cartilage, subchondral bone may be exposed and damaged, with regrowth leading to a
proliferation of ivory-like, dense, reactive bone in central areas of cartilage loss, a process called
eburnation.[3] The patient increasingly experiences pain upon weight bearing, including walking
and standing. As a result of decreased movement because of the pain, regional muscles may
atrophy, and ligaments may become more lax.[4] OA is the most common form of arthritis,[4] and
the leading cause of chronic disability in the United States.[5]

"Osteoarthritis" is derived from the Greek word "osteo", meaning "of the bone", "arthro",
meaning "joint", and "itis", meaning inflammation, although the "itis" of osteo arthritis is
somewhat of a misnomer -- inflammation is not a conspicuous feature of the disease.
Osteoarthritis is not to be confused with rheumatoid arthritis, an autoimmune disease with joint
inflammation as a main feature. A common misconception is that OA is due solely to wear and
tear, since OA typically is not present in younger people. However, while age is correlated with
OA incidence, this correlation may illustrate that OA is a process that takes time to develop -- or
that repair and regeneration that may keep pace with damage in the joints of younger people but
slow with age. There is sometimes a diagnosable underlying cause for OA, in which case it is
described as secondary OA. In the majority of cases no cause can be identified, described as
primary OA. "Degenerative arthritis" is often used as a synonym for OA, but the latter involves
both degenerative and regenerative changes.

OA affects about 8 million people in the United Kingdom and nearly 27 million people in the
United States, where it accounts for 25% of visits to primary care physicians and half of all
NSAID (Non-Steroidal Anti-Inflammatory Drugs) prescriptions. It is estimated that 80% of the
US population will have radiographic evidence of OA by age 65, although only 60% of those
will show symptoms.[6] In the United States, hospitalizations for osteoarthritis soared from about
322,000 in 1993 to 735,000 in 2006.[7]

[edit] Classification
Osteoarthritis can be classified into either primary or secondary depending on if there is or is not
an identifiable underlying cause.

[edit] Signs and symptoms

Heberden's nodes may form in osteoarthritis

The main symptom is acute pain, causing loss of ability and often stiffness. "Pain" is generally
described as a sharp ache, or a burning sensation in the associate muscles and tendons. OA can
cause a crackling noise (called "crepitus") when the affected joint is moved or touched, and
patients may experience muscle spasm and contractions in the tendons. Occasionally, the joints
may also be filled with fluid. Humid and cold weather increases the pain in many patients.[8][9]

OA commonly affects the hands, feet, spine, and the large weight bearing joints, such as the hips
and knees, although in theory, any joint in the body can be affected. As OA progresses, the
affected joints appear larger, are stiff and painful, and usually feel worse, the more they are used
throughout the day, thus distinguishing it from rheumatoid arthritis.

In smaller joints, such as at the fingers, hard bony enlargements, called Heberden's nodes (on the
distal interphalangeal joints) and/or Bouchard's nodes (on the proximal interphalangeal joints),
may form, and though they are not necessarily painful, they do limit the movement of the fingers
significantly. OA at the toes leads to the formation of bunions, rendering them red or swollen.
Some people notice these physical changes before they experience any pain.[10]

OA is the most common cause of joint effusion, sometimes called water on the knee in lay terms,
an accumulation of excess fluid in or around the knee joint. [11]

[edit] Causes
Exercise, including running in the absence of injury, has not been found to increase one's risk of
developing osteoarthritis.[12] Some investigators believe that mechanical stress on joints underlies
all osteoarthritis, with many and varied sources of mechanical stress, including misalignments of
bones caused by congenital or pathogenic causes; mechanical injury; being overweight; loss of
strength in muscles supporting joints; and impairment of peripheral nerves, leading to sudden or
uncoordinated movements that overstress joints.[13]

[edit] Primary

Primary OA in the left knee of an elderly female.

This type of OA is a chronic degenerative disorder related to but not caused by aging, as there
are people well into their nineties who have no clinical or functional signs of the disease. As a
person ages, the water content of the cartilage decreases[14] as a result of a reduced proteoglycan
content, thus causing the cartilage to be less resilient. Without the protective effects of the
proteoglycans, the collagen fibers of the cartilage can become susceptible to degradation and
thus exacerbate the degeneration. Inflammation of the surrounding joint capsule can also occur,
though often mild (compared to that which occurs in rheumatoid arthritis). This can happen as
breakdown products from the cartilage are released into the synovial space, and the cells lining
the joint attempt to remove them. New bone outgrowths, called "spurs" or osteophytes, can form
on the margins of the joints, possibly in an attempt to improve the congruence of the articular
cartilage surfaces. These bone changes, together with the inflammation, can be both painful and
debilitating.

A number of studies have shown that there is a greater prevalence of the disease between siblings
and especially identical twins, indicating a hereditary basis [15]. Up to 60% of OA cases are
thought to result from genetic factors.

Both primary generalized nodal OA and erosive OA (EOA. also called inflammatory OA) are
sub-sets of primary OA. EOA is a much less common, and more aggressive inflammatory form
of OA which often affects the DIPs and has characteristic changes on X-Ray.

[edit] Secondary

This type of OA is caused by other factors but the resulting pathology is the same as for primary
OA:

 Congenital disorders of joints

 Diabetes.
 Inflammatory diseases (such as Perthes' disease), (Lyme disease), and all chronic forms of
arthritis (e.g. costochondritis, gout, and rheumatoid arthritis). In gout, uric acid crystals cause
the cartilage to degenerate at a faster pace.
 Injury to joints, as a result of an accident.
 Septic arthritis ( a infection of a joint )
 Ligamentous deterioration or instability may be a factor.
 Marfan syndrome
 Obesity
 Alkaptonuria
 Hemochromatosis and Wilson's disease

[edit] Diagnosis
There is no laboratory or pathological definition of osteoarthritis, and therefore no accepted
laboratory tests to diagnose it.[10] Diagnosis can often be made with reasonable certainty by
clinical examination[16][17] unless there is reason to suspect osteonecrosis or surgery is being
considered, in which case imaging or blood tests may be necessary. [18] Confirmation can be done
through x-rays. This is possible because loss of cartilage, subchondral ("below cartilage")
sclerosis, subchondral cysts from synovial fluid entering small microfractures under pressure,
narrowing of the joint space between the articulating bones, and bone spur formation
(osteophytes) - from increased bone turnover in this condition, show up clearly on x-rays. Plain
films, however, often do not correlate well with the findings of physical examination of the
affected joints or with the degree of pain. [18] Usually other imaging techniques are not necessary
to clinically diagnose osteoarthritis.
In 1990, the American College of Rheumatology, using data from a multi-center study,
developed a set of criteria for the diagnosis of hand osteoarthritis based on hard tissue
enlargement and swelling of certain joints. These criteria were found to be 92% sensitive and
98% specific for hand osteoarthritis versus other entities such as rheumatoid arthritis and
spondyloarthropities [19].

Related pathologies whose names may be confused with osteoarthritis include pseudo-arthrosis.
This is derived from the Greek words pseudo, meaning "false", and arthrosis, meaning "joint."
Radiographic diagnosis results in diagnosis of a fracture within a joint, which is not to be
confused with osteoarthritis which is a degenerative pathology affecting a high incidence of
distal phalangeal joints of female patients.

[edit] Treatment
Treatment of OA consists of exercise, manual therapy, lifestyle modification, medication and
other interventions to alleviate pain.

[edit] Lifestyle modification

No matter the severity or location of OA, conservative measures such as weight control,
appropriate rest, exercise, and the use of mechanical support devices can be beneficial. In OA of
the knees, knee braces can be helpful. A cane, or a walker can reduce pressure on involved leg
joints which can be helpful for walking and support. Regular exercise such as walking or
swimming, or other low impact activities are encouraged. Applying local heat before, and/or cold
packs after exercise, can help relieve pain, as can relaxation techniques. Weight loss can relieve
joint stress and may delay progression although research supporting this is equivocal.

Physical measures

Proper advice and guidance by health care providers such as chiropractors, physical therapists,
occupational therapists, and medical doctors is important in OA management, enabling people
with this condition to improve their quality of life.

Functional, gait, and balance training has been recommended to address impairments of
proprioception, balance, and strength in individuals with lower extremity arthritis. These deficits
can contribute to higher fall risk in older individuals.[20]

Moderate exercise leads to improved functioning and decreased pain in people with osteoarthritis
of the knee.[21]

Adequate joint motion and elasticity of periarticular tissues are necessary for cartilage nutrition
and health, protection of joint structures from damaging impact loads, function, and comfort in
daily activities. Exercise to regain or maintain motion and flexibility by low-intensity, controlled
movements that do not cause increased pain. Muscle weakness around an osteoarthritic joint is a
common finding. Progressive resistive/strengthening exercises load muscles in a graduated
manner to allow for strengthening while limiting tissue injury.[22]
Splinting of the thumb for OA of the base of the thumb leads to improvements after one year.[23]

In 2002, a randomized, blinded assessor trial was published showing a positive effect on hand
function with patients who practiced home joint protection exercises (JPE). Grip strength, the
primary outcome parameter, increased by 25% in the exercise group versus no improvement in
the control group. Global hand function improved by 65% for those undertaking JPE. [24]

Education

Patient education has been shown to be helpful in the self-management of patients with arthritis
in decreasing pain, improving function, reducing stiffness and fatigue, and reducing medical
usage.[25] A meta-analysis has shown patient education can provide on average 20% more pain
relief when compared to NSAIDs alone in patients with hip OA or rheumatoid arthritis.[26]

[edit] Medication

Paracetamol

Paracetamol (acetaminophen), is commonly used to treat the pain from OA, and was
recommended in 16 of 16 guidelines evaluated in a 2007 review of existing guidelines.[27] A
randomized controlled trial comparing paracetamol with ibuprofen in x-ray-proven mild to
moderate osteoarthritis of the hip or knee found equal benefit.[28] However, paracetamol at a dose
of 4 grams per day can increase liver function tests.[29] In 2006, however, a Cochrane review[30]
found a small benefit (effect size of 0.13) from paracetamol, suggesting questionable clinical
significance.[31] There is equivocal evidence for gastrointestinal bleeding or renal (kidney)
damage with long-term use of 4 g/day.[31] NSAIDs appear to be more potent, but pose greater risk
of side-effects.[30]

Non-steroidal anti-inflammatory drugs

In more severe cases, non-steroidal anti-inflammatory drugs (NSAID) reduce both the pain and
inflammation; they all act by inhibiting the formation of prostaglandins, which play a central role
in inflammation and pain. However, it should be noted that this class of drugs is not without risk
for adverse events including increased gastrointestinal bleeding.[32] Most prominent drugs in the
class include diclofenac, ibuprofen, naproxen and ketoprofen. High oral drug doses are often
required. However, diclofenac has been found to cause damage to the articular cartilage. Even
more importantly all systemic NSAIDs are rather taxing on the gastrointestinal tract, and may
cause stomach upset, cramping, diarrhea, and peptic ulcer. Such systemic adverse side effects are
normally not observed when using NSAIDs topically, that is, on the skin around the target area.
The typically weak and/or short-lived therapeutic effect of such topical treatments may be
improved by using the drug in more modern formulations, including or ketoprofen associated
with the Transfersome carriers or diclofenac in DMSO solution.

Another type of NSAID, COX-2 selective inhibitors (such as celecoxib, rofecoxib and
valdecoxib) have often been used but are no more effective than the other NSAIDs. The latter
two NSAIDs (rofecoxib and valdecoxib) carry an elevated risk for cardiovascular disease, and
have been withdrawn from the market. Studies suggest that naproxen has the lowest
cardiovascular risk. [18]

Corticosteroids

Oral steroids are not recommended in the treatment of OA because of their modest benefit and
high rate of adverse effects. However intra - articular corticosteroid temporarily improve
symptoms as discussed below.

Opioid analgesics

For moderate to severe pain a opioid analgesic such as morphine or codeine may be useful.

Topical

There are several NSAIDs available for topical use (e.g. diclofenac, ibuprofen, and ketoprofen)
with little, if any, systemic side-effects and at least some therapeutic effect. The more modern
NSAID formulations for direct use, containing the drugs in an organic solution or the
Transfersome carrier based gel, reportedly, are as effective as oral NSAIDs.

Creams and lotions, containing capsaicin, are effective in treating pain associated with OA if
they are applied with sufficient frequency.

Injectable

A 2005 review of injections of hyaluronic acid, known as viscosupplementation, did not find that
it led to clinical improvement in OA.[33] A subsequent 2009 study found similar results.[34]
Injection of glucocorticoids (such as hydrocortisone) leads to short term pain relief that may last
between a few weeks and a few months.[35]

[edit] Surgery

If the above management is ineffective, joint replacement surgery may be required. Individuals
with very painful OA joints may require surgery such as fragment removal, repositioning bones,
or fusing bone to increase stability and reduce pain. Arthroscopic surgical intervention for
osteoarthritis of the knee has been found to be no better than placebo at relieving symptoms.[36]

[edit] Alternative treatments

The majority of patients with arthritis have tried alternative treatments for their pain. Some
studies have reported benefits for these approaches, including acupuncture and some
supplements. However, the response rates tend to be low and there is concern about bias in many
studies.[10]

Acupuncture
A 2006 Cochrane review supported the use of acupuncture for pain management in osteoarthritis.
The benefit of acupuncture was found to be greater than that achieved with sham treatment and
the risk were minimal.[37] Further reviews have supported these findings.[38][39][40][41][42]
Acupuncture however does not seem to produce long-term benefits.[43]

Glucosamine/Chondroitin

There is controversy about glucosamine's effectiveness for OA of the knee.[44] A 2005 review
concluded that glucosamine may improve symptoms of OA and delay its progression.[45]
However, a subsequent large study suggests that glucosamine is not effective in treating OA of
the knee[46], and a 2007 meta-analysis that included this trial states that glucosamine
hydrochloride is not effective.[47]. In vitro analysis of glucosamine has revealed that glucosamine
inhibits cartilage cell characteristics, [48] but a magnetic resonance imaging study reported in
2009 that glucosamine had no detectable effect on osteoarthritis of the knee.[49] There is a
"striking" difference between the results reported from trials involving glucosamine sulfate as
compared to glucosamine hydrochloride, with glucosamine sulfate reporting an effect size of
0.44 compared to a 0.06 effect size from glucosamine hydrochloride; Osteoarthritis Research
Society International recommends discontinuing glucosamine if no effect is observed after six
months.[31] There is concern that industry bias has affected the earlier trials, although a 2008
OARSI consensus review stated that this was "unsubstantiated". No adverse effects have been
observed. The European League Against Rheumatism practice guidelines recommend
glucosamine.[50]

Chondroitin sulfate has also become a widely used dietary supplement for treatment of
osteoarthritis, both in combination with glucosamine and by itself. A meta-analysis of
randomized controlled trials found no benefit from chondroitin,[51] although this meta-analysis
included only 3 trials, one which had "an exceptionally high placebo response" and one which
was published as only an abstract.[31]

Other supplements

 S-Adenosyl methionine (SAMe) has been tested; a review of 10 studies found that it has an
effect on pain relief similar to nonsteroidal anti-inflammatory drugs.[52] A 2004 trial comparing
SAMe and celecoxib found that during the first month the SAMe group reported more pain, but
thereafter there was no significant difference between SAMe and celecoxib on reducing pain.
The SAMe group reported somewhat fewer side-effects, consistent with a prior review. [53]

 Frankincense resin from Boswellia serrata trees—Indian frankincense is a traditional treatment

for arthritis in Ayurvedic medicine.[54]

 Bromelain, protease enzymes extracted from the plant family Bromeliaceae (pineapple), blocks
some proinflammatory metabolites.[55]

 Antioxidants, including vitamins C and E in both foods and supplements, provide pain relief from
OA.[56]
  Ginger (rhizome) extract - has improved knee symptoms moderately. [57]

 Selenium deficiency has been correlated with a higher risk and severity of OA. [58]

 Vitamin B9 (folate) and B12 (cobalamin) taken in large doses has been thought to reduce OA
hand pain in one very small, non-quantitative study of 25 people, the results of which are
extremely vague at best.[59]

 Vitamin D deficiency has been reported in patients with OA, and supplementation with Vitamin
D3 is recommended for pain relief.[60]

 A clay-based mineral supplement containing over 60 individual macro and trace minerals
essential to health. In a 2005 randomized, placebo-controlled clinical trial on 100 patients
suffering from mild to moderate osteoarthritis of the knee, it was concluded that SierraSil
improves symptoms of osteoarthritis including joint pain, flexibility and mobility, as assessed by
the WOMAC scale for osteoarthritis [61]The improvements on joint pain and function were rapid
and observed within 1 week of treatment, significantly faster than placebo. These results are
further supported by a human pilot study [62]and mechanism of action study[63]demonstrating the
cartilage preserving role of SierraSil. SierraSil was awarded a US patent in November 2009 as a
nutritional supplement for osteoarthritis.[64]

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