A prospective, randomized, double-blind, multicenter comparative study on the safety and efficacy of Celecoxib and GCSB-5, dried extracts of six herbs, for the treatment of osteoarthritis of knee joint

Systematic review and network meta-analysis on the efficacy and safety of parmacotherapy for hand osteoarthritis

OBJECTIVE

Hand osteoarthritis poses a significant health challenge globally due to its increasing prevalence and the substantial burden on individuals and the society. In current clinical practice, treatment options for hand osteoarthritis encompass a range of approaches, including biological agents, antimetabolic drugs, neuromuscular blockers, anti-inflammatory drugs, hormone medications, pain relievers, new synergistic drugs, and other medications. Despite the diverse array of treatments, determining the optimal regimen remains elusive. This study seeks to conduct a network meta-analysis to assess the effectiveness and safety of various drug intervention measures in the treatment of hand osteoarthritis. The findings aim to provide evidence-based support for the clinical management of hand osteoarthritis.

METHODS

We performed a comprehensive search across PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials was conducted until September 15th, 2022, to identify relevant randomized controlled trials. After meticulous screening and data extraction, the Cochrane Handbook's risk of bias assessment tool was applied to evaluate study quality. Data synthesis was carried out using Stata 15.1 software.

RESULTS

21 studies with data for 3965 patients were meta-analyzed, involving 20 distinct Western medicine agents. GCSB-5, a specific herbal complex that mainly regulate pain in hand osteoarthritis, showed the greatest reduction in pain [WMD = -13.00, 95% CI (-26.69, 0.69)]. CRx-102, s specific medication characterized by its significant effect for relieving joint stiffness symptoms, remarkably mitigated stiffness [WMD = -7.50, 95% CI (-8.90, -6.10)]. Chondroitin sulfate displayed the highest incidence of adverse events [RR = 0.26, 95% CI (0.06, 1.22)]. No substantial variation in functional index for hand osteoarthritis score improvement was identified between distinct agents and placebo.

CONCLUSIONS

In summary, GCSB-5 and CRx-102 exhibit efficacy in alleviating pain and stiffness in HOA, respectively. However, cautious interpretation of the results is advised. Tailored treatment decisions based on individual contexts are imperative.

Medical treatment of osteoarthritis: botanical pharmacologic aspect

Osteoarthritis (OA) is the most common form of arthritis, and its prevalence is expected to further increase as our society ages. Despite many approaches to cure OA, no drugs are currently proven to modulate the progression of OA. Nowadays, new OA treatment options are holistically developed and one of the approaches of treatment option is botanical drugs. Some botanical drugs for OA have shown both therapeutic effect comparable to refined drugs in small studies and fewer side effects. Hence, there are various health functional foods which are known to relieve symptoms of OA. However, since there are many botanical products, clinicians are not familiar to the efficacy of each botanical product, making it challenging to use them appropriately in clinical practice. Here, we summarize the botanical products available for treating OA, including prescription botanical drugs and health functional foods available in Korea. Further studies and the purification of effective molecules from botanical products will be necessary in future.

Efficacy of Herbal Medicine in Hand Osteoarthritis: A Narrative Review

OBJECTIVE

Osteoarthritis (OA) is one of the most prevalent joint disorders in the world that has placed an enormous economic and social burden on governments and healthcare sectors in many countries. Hand OA (HOA) is the most common peripheral arthritis, which is less investigated than knee and hip OA. Due to limited approved drug choices and adverse effects of long-term use of current regimens, we aimed to review the existing evidence that were used as oral herbal medicine to treat HOA.

METHODS

The PubMed database was searched for both observational and interventional studies that have investigated herbal medicine safety and efficacy in HOA, written in English and published between 2010 and 2022.

RESULTS

A total of 5 original articles fulfilled the inclusion criteria, and each article assessed a different herbal regimen. Overall, it seems desirable to add specific herbal treatments to the regimen of HOA patients, specifically in case of early stages of HOA.

CONCLUSION

Currently, the need for a low-risk alternative treatment in HOA patients is felt more than ever. There are reliable references relating to the safety of Korean red ginseng, GCSB-5, XLGB, and GS-GCu in these patients, although their efficacy was limited. Additionally, herbs like curcumin and Boswellia serrata have positively affected patients with knee osteoarthritis. However, there is a lack of strong evidence supporting their effectiveness in hand osteoarthritis (HOA). This emphasizes the potential benefits that these herbs may have for HOA patients.

GCSB-5 regulates inflammatory arthritis and pain by modulating the mitogen-activated protein kinase signaling pathway in a murine model of rheumatoid arthritis

Objectives

This study aimed to determine whether GCSB-5 has anti-inflammatory and antinociceptive effects in mice with collagen-induced arthritis (CIA), an animal model of rheumatoid arthritis (RA), and investigate the influence of GCSB-5 on the mitogen-activated protein kinase (MAPK) pathway.

Materials and methods

The experimental animal study was designed to include five groups: CIA mice treated with GCSB-5 (300 mg/kg), GCSB-5 (600 mg/kg), celecoxib (60 mg/kg), or saline for four weeks, and nontreated control mice. The clinical severity of arthritis was scored. Nociceptive thresholds were measured by using a von Frey dynamic plantar analgesimeter. The MAPK pathway was evaluated in mouse synovium. The expression of channels associated with pain signaling was assessed by western blot and immunohistochemical staining.

Results

GCSB-5 treatment diminished the severity of clinical arthritis and increased the nociceptive threshold in mice with CIA. Celecoxib, a positive control drug, also showed comparable changes. Clinical arthritis scores were inversely related to mechanical thresholds. GCSB-5 administration decreased the levels of anti-type II collagen antibody and inflammatory cytokines in the sera of mice with CIA. Furthermore, ERK, p38 MAPK, and JNK phosphorylation were downregulated and TRPV1 and ASIC3 expression were decreased in the synovium of GCSB-5-treated mice compared to salinetreated mice. Interleukin-6-induced TRPV1 and ASIC3 upregulation were also inhibited by GCSB-5 in human RA fibroblast-like synoviocytes in vitro.

Conclusion

GCSB-5 decreased inflammatory arthritis and pain in a murine model of RA. The results present evidence that GCSB-5 may be beneficial for relieving pain as well as decreasing inflammation in autoimmune arthritis, such as RA.

A Retrospective Chart Review of 122 Inpatients with Knee Osteoarthritis Treated with Korean Medicine: An Analysis of the Effects of Treatment

Background: Korean medicine treatment was assessed in patients with knee osteoarthritis (OA) according to subgroups of: sex, age, cause of knee OA, body mass index, hospitalization period, history, OA compartment, phenotype, and comorbidity. Methods: A retrospective review was performed of 122 inpatients who were admitted to the Hospital of Korean Medicine for Korean medicine treatment of knee pain, and were diagnosed with knee OA based on magnetic resonance imaging findings. Analysis of patient subgroups (sex, age, cause of knee OA, body mass index, hospitalization period, history, OA compartment, phenotype, and comorbidity) was carried out and treatments including acupuncture, cupping, pharmacopuncture, herbal medicine, chuna therapy, medicinal steaming therapy, manual therapy, and extracorporeal shock wave therapy were listed. The numeric rating scale (NRS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 5-level EuroQol- 5 Dimension (EQ-5D-5L) scores were measured before and after treatment to assess the effects of treatment on pain and quality of life. Results: Seventeen males and 105 females were included in this study. Most patients were in their 60s. In the total study population, NRS, WOMAC, and EQ-5D-5L scores were improved statistically significant when comparing before and after treatment. The NRS and WOMAC scores improved statistically significant in the medial, patellofemoral, medial + patellofemoral, medial + lateral + patellofemoral compartment. Conclusion: Korean medicine treatment significantly reduced pain, stiffness, and physical dysfunction, and improved the quality of life of patients with knee OA, suggesting that it may be an effective alternative to the current conservative treatments.

Efficacy and safety of celecoxib combined with JOINS in the treatment of degenerative knee osteoarthritis: study protocol of a randomized controlled trial

Background

The aim of this study will be to investigate the therapeutic effect and safety of non-steroidal anti-inflammatory drugs (NSAIDs) along with symptomatic slow-acting drugs for the treatment of osteoarthritis (SYSADOA), JOINS tablets, for degenerative knee osteoarthritis (OA) treatment and to determine the analgesic and anti-inflammatory effects of the combination therapy. In addition, we will investigate whether JOINS treatment alone after NSAID and JOINS combination treatment is effective in relieving and maintaining knee OA symptoms.

Methods

This study will be a prospective, randomized, double-blind endpoint study design. All patients will be randomly assigned to either intervention (celecoxib+JOINS) or control (celecoxib+placebo) groups. In Part 1, the intervention group will be administered celecoxib once a day and JOINS three times a day for a total of 12 weeks. In the control group, celecoxib will be administered once a day and JOINS placebo three times a day for a total of 12 weeks. In Part 2, JOINS alone and JOINS placebo alone will be administered for an additional 24 weeks in both groups, respectively. The primary endpoint will be the amount of change during the 12 weeks as assessed using the Western Ontario and McMaster Universities Osteoarthritis Index total score compared with baseline. The secondary endpoint will be the amount of change at 1, 4, 12, 24, and 36 weeks from the baseline for pain visual analog scale, Brief Pain Inventory, Short Form Health Survey-36 and biomarkers.

Results

The trial was registered with Clinical-Trials.gov (NCT04718649). The clinical trial was also registered on Clinical Research Information Service (CRIS) with the trial registration number KCT0005742.

Conclusions

The combination treatment of the most commonly used SYSADOA drug, JOINS, and selective COX-2 inhibitor celecoxib as the representative NSAID for knee OA treatment, can be compared with celecoxib alone treatment to determine the safety or therapeutic effect.

Global Research Trends of Herbal Medicine for Pain in Three Decades (1990-2019): A Bibliometric Analysis

Purpose

The aim of this study was to explore the global research trends of herbal medicine for pain from 1990 to 2019, using bibliometric methods, and explore international collaborations, intellectual structure, the evolution of active topics, emerging trends, and research frontiers.

Methods

Articles on herbal medicine for pain were retrieved from WoSCC. Two information visualization softwares including CiteSpace and HistCite were used to process bibliographic catalogs. Identification of international collaborations, intellectual structure, the evolution of active topics, emerging trends, and research frontiers were performed based on results from bibliometric analysis.

Results

A total of 2986 original articles published between 1990 and 2019 were identified based on the inclusion criteria. The number of publications on herbal medicine for pain in WoSCC significantly increased. China ranked highest in the number of scientific outputs; however, articles with the highest citation rates were found to be from the United States. China–Japan reported the most active collaborations, whereas Kyung Hee University from South Korea was the most productive institution. Zhang Y was the most productive author, whereas research by Sherman KJ and Vane JR had the highest influence. Journal of Ethnopharmacology was the most active journal, whereas Integrative and Complementary Medicine was the most active research area. History of herbal medicine for pain research comprises three major phases of activities. The main points of focus of bibliometric analysis of herbal medicine for pain include “knee osteoarthritis”, “cancer”, “low back pain”, etc.. Moreover, research on mechanisms of action of herbal medicine for pain remains at the forefront of this field.

Conclusion

This paper provides a basis for future development of research on herbal medicine for pain, which may help researchers explore new directions for future research and identify new perspectives on potential collaborations in this field.

Formulation optimization and characterization of transdermal film of curcumin by response surface methodology

Objective

India is referred as goldmine of herbal drugs but still lack of optimization of herbal drugs, which has kept us on the back foot. The rationale of the study is to prepare optimized transdermal drug delivery system of curcumin employing response surface methodology to study the collective effect of independent variables like concentration of ethyl cellulose, hydroxyl propyl methyl cellulose and dibutyl phthalate which significantly influenced characteristics like percentage elongation and in vitro drug release.

Method

Twenty formulations containing varying concentrations of polymers and permeation enhancer were prepared using solvent casting technique.

Result

The study revealed that the effect of dibutyl phthalate (DBP) concentration was the highest on percentage elongation (P < 0.0001), while hydroxy propyl methyl cellulose (HPMC) concentration exhibited pronounced effect on drug release (P < 0.0001) through dialysis membrane. Linear model fitted the best for curcumin release and elongation for all formulations. According to Derringer’s desirability prediction tool, the composition of optimized film was found to be 242.14% of HPMC, 109.59% of ethyl cellulose (EC), and 1.03% of DBP. Under these conditions, the optimized patch exhibited a predicted value of %elongation and in vitro drug release of 94.35% and 80.0306%, respectively, which was comparable to the actual values of percent elongation and in vitro drug release i.e. 95.02% and 81.03% respectively. FTIR and thermal studies were also performed which revealed no interaction or complexation between drug and excipients. The ex vivo study performed using rat skin showed that the cumulative drug release from the optimized patch showed flux of (30.68 ± 18) µg/cm²/h.

Conclusion

It can be concluded that in future if proper optimization of herbal formulations is carried out, they can become the first choice for patients as compare to synthetic drugs.

Novel Herbal Topical Patch Containing Curcumin and Arnica montana for the Treatment of Osteoarthritis

BACKGROUND

Osteoarthritis (OA) ranks fifth among all forms of disability affecting 10% of the world population. Current treatments available are associated with multiple side effects and do not slow down the progression of the disease. Moreover, no such effective treatment is available to date in various systems of medicine to treat osteoarthritis. Curcumin and Arnica have shown evident clinical advances in the treatment of osteoarthritis.

OBJECTIVE

The aim of the present study was to design, optimize and characterize novel herbal transdermal patches of curcumin and Arnica montana using factorial design.

METHODS

A multiple factorial design was employed to investigate the effect of hydroxypropyl methyl cellulose, ethyl cellulose and jojoba oil on elongation and drug release. Transdermal patches were evaluated by FTIR, DSC, FESEM, ex vivo drug permeation, anti osteoarthritic activity and analgesic activity.

RESULTS

Independent variables exhibited a significant effect on the physicochemical properties of the prepared formulations. The higher values of drug release and elongation were observed with the higher concentration of hydroxypropyl methylcellulose and jojoba oil. Anti osteoarthritic activity was assessed by complete Freund's adjuvant arthritis model; using rats and analgesic activity by Eddy's hot plate method, using mice. Combination patch exhibited good anti osteoarthritic and analgesic activity as compare to individual drug patches.

CONCLUSION

The design results revealed that the combination patch exhibited good physicochemical, anti osteoarthritic and analgesic activity for the treatment of osteoarthritis in animals. More plants and their combinations should be explored to get reliable, safe and effective formulations that can compete with synthetic drugs.

Comparative efficacy and safety of Verbascox® - a proprietary herbal extract capable of inhibiting human cyclooxygenase-2 - and celecoxib for knee osteoarthritis

The aim of this randomized, single-blind, active-controlled pilot study was to investigate the clinical efficacy of oral supplementation with Verbascox^®, a proprietary herbal extract capable of inhibiting human cyclooxygenase-2 (COX-2), in patients with mild-to-moderate osteoarthritis (OA) of the knee. Patients in the control group (n = 50) did not undergo any treatment (watchful waiting). Patients in the Verbascox^® group (n = 50) received oral supplementation (800 mg/day) with the herbal extract for 2 weeks. The final study group consisted of patients (n = 50) who received celecoxib, a known pharmacological inhibitor of COX-2, 200 mg/day for 2 weeks. Examining physicians and laboratory personnel were blinded to group assignment, whereas patients were unblinded. All participants were evaluated using standard measures of pain relief and improvement in functional capacity at baseline, after 1 week, and at the end of the 2-week treatment course. Moreover, serum levels of substance P (SP), a member of the tachykinin family of neuropeptides involved in pain perception, were measured at the three time points. Both Verbascox^® and celecoxib reduced pain, improved functional capacity, and lowered serum SP levels at 2 weeks compared with baseline, without significant inter-arm differences. Both Verbascox^® and celecoxib showed a limited number of treatment-emergent adverse events. In summary, oral supplementation with Verbascox^® (800 mg/day) in patients with mild-to-moderate OA of the knee is as effective and safe as a standard therapeutic dose of celecoxib in terms of pain relief and improvement in functional capacity after a 2-week treatment course.

Effect Of E-OA-07 On Improving Joint Health And Mobility In Individuals With Knee Osteoarthritis: A Randomized, Double-Blind, Placebo-Controlled, Parallel Group Study

Aim

The aim of the present study was to evaluate the effect of E-OA-07 on individuals having osteoarthritis of the knee.

Background

Lanconone^® (E-OA-07) is a widely marketed dietary supplement which has been previously studied in different clinical settings for managing chronic joint pain. This was a confirmatory study planned at a lowered dose regimen with the purpose of improving compliance and reducing consumer cost.

Methods

Male and female participants aged between 40 and 65 years, with history of joint pain for at least 3 years, were recruited. Knee joint dysfunction of grade II/III was radiographically characterized as per Kellgren-Lawrence system of classification. Enrolled participants were randomized to receive E-OA-07 at a dose of 1000 mg/day or placebo over a period of 8 weeks. The primary efficacy parameter was assessment of change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score. Whereas, the secondary parameters explored in the study included WOMAC subscales of stiffness and physical function, EQ-5D-5L questionnaire, systemic inflammatory marker (hs-CRP) and self-assessment of treatment satisfaction.

Results

At the end of 8 weeks, joint pain severity as per WOMAC was found to be significantly reduced in the E-OA-07 group as compared to placebo (p<0.001). Similar improvement was observed in the subscales of stiffness and physical function which corresponds to significant improvement in the quality-of-life standards of E-OA-07 participants (p<0.001), reporting higher treatment satisfaction (p<0.001).

Conclusion

E-OA-07 at a dose of 1000 mg/day was able to significantly reduce joint pain and thereby improve joint mobility in study participants. At the end of the study period, there was a clinically relevant change of 45.55%, 45.91% and 38.19% for pain, stiffness and physical function, respectively. Moving forward, studies could be planned for understanding the cartilage regenerative properties of E-OA-07.

Efficacy and safety of Cortex Eucommiae (Eucommia ulmoides Oliver) extract in subjects with mild osteoarthritis: Study protocol for a 12-week, multicenter, randomized, double-blind, placebo-controlled trial

BACKGROUND

Osteoarthritis (OA) is a major degenerative disease that affects the elderly. The global prevalence of OA is increasing annually. However, current treatments are unable to halt the progress of OA. At present, pharmacological treatments such as non-steroidal anti-inflammatory drugs (NSAIDs) and cyclooxygenase-2 (COX-2) inhibitors control the pain; however, there may be side effects to these medications. We hypothesized that Cortex Eucommiae (CE; Eucommia ulmoides Oliver) extract, which is used as a dietary supplement, may slow down or prevent OA.

METHODS

This is a protocol for a 12-week, multicenter, randomized, double-blind, placebo-controlled, parallel-group study to evaluate the efficacy and safety of CE extract in subjects with mild OA. One-hundred subjects with mild OA will be recruited and randomly divided in a 1:1 ratio into 2 groups. One group will receive CE extract for 12 weeks and the other group will receive placebo for 12 weeks. Outcomes will be evaluated by using the visual analog scale (VAS), Korean-Western Ontario and McMaster Universities index (K-WOMAC), Korean-Short Form health survey-36 score (KSF-36), and laboratory test results.

DISCUSSION

This clinical trial is expected to provide evidence of the efficacy and safety of CE extract as a treatment for mild OA.

TRIAL REGISTRATION

Clinical Trials.gov NCT03744611, registered on November 12, 2018, at https://clinicaltrials.gov/ct2/show/NCT03744611.

Natural Products as Sources of Novel Drug Candidates for the Pharmacological Management of Osteoarthritis: A Narrative Review

Osteoarthritis is a chronic degenerative articular disorder. Formation of bone spurs, synovial inflammation, loss of cartilage, and underlying bone restructuring have been reported to be the main pathologic characteristics of osteoarthritis symptoms. The onset and progression of osteoarthritis are attributed to various inflammatory cytokines in joint tissues and fluids that are produced by chondrocytes and/or interact with chondrocytes, as well as to low-grade inflammation in intra-articular tissues. Disruption of the equilibrium between the synthesis and degradation of the cartilage of the joint is the major cause of osteoarthritis. Hence, developing a promising pharmacological tool to restore the equilibrium between the synthesis and degradation of osteoarthritic joint cartilage can be a useful strategy for effectively managing osteoarthritis. In this review, we provide an overview of the research results pertaining to the search for a novel candidate agent for osteoarthritis management via restoration of the equilibrium between cartilage synthesis and degradation. We especially focused on investigations of medicinal plants and natural products derived from them to shed light on the potential pharmacotherapy of osteoarthritis.

Survey of Integrative Treatment Practices of Korean Medicine Doctors for Cervical Disc Herniation: Preliminary Data for Clinical Practice Guidelines

A survey study was conducted in Korean medicine doctors who provide nonsurgical integrative treatment for cervical disc herniation (CDH) at spine-specialty hospitals to assess usual treatment practices, diagnosis and treatment methods, and related adverse events for CDH. The questionnaire was jointly developed by clinical experts and methodology experts and was administered to 197 Korean medicine doctors (response rate: 84.9% (n = 197/232)) practicing at spine-specialty Korean medicine hospitals for analysis of general sociodemographic information, practice patterns of CDH including diagnosis and treatment strategies, CDH prognosis, and treatment safety. The average clinical experience of respondents was 9.3±6.4 years, and 4.0±1.8 weeks were regarded to be needed for CDH pain to decrease by 50% and 9.1±3.4 weeks to decrease by 80%. Eight-Principle Pattern and Meridian System Identification were the most commonly used Korean medicine syndrome differentiation methods, and CDH was most often considered to be a result of Qi stagnation and Blood coagulation. The Spurling test was reported to be important in physical examination, and magnetic resonance (MR) images were mostly used for diagnosis and treatment of CDH of various diagnostic tools. Treatment mainly consisted of a nonsurgical, integrative multimodal approach comprising acupuncture, pharmacopuncture, herbal medicine, and Chuna manual therapy. Shinbaro pharmacopuncture and Chungpa-jun, which are well-established herbal treatments supported by evidence, were considered to be of high importance in CDH treatment. With regard to safety, acupuncture was considered to be the safest, while bee venom pharmacopuncture was of highest concern due to potential hypersensitivity. This study is the first report to investigate current practice patterns and approach of Korean medicine doctors to CDH treatment. This data may be of significance to Korean medicine doctors in drawing clinical guidelines and conducting randomized controlled trials (RCTs) to generate high-level evidence on the effectiveness of nonsurgical integrative medicine treatments for CDH.

Nonsurgical integrative Korean Medicine treatment of discal cyst: A case report and a retrospective chart review analysis

RATIONALE

Discal cysts are rare lesions characterized by pain caused by neurogenic compression with similar symptoms as those of disc herniation. This study aims to report the spontaneous regression of discal cyst achieved through nonsurgical integrative Korean Medicine treatment and the clinical epidemiological features of discal cyst cases collected from 4 institutions.

PATIENT CONCERNS

A 31-year-old woman had low back pain and radiating pain equivalent to a numeral rating scale (NRS) of 8 and had limitations in daily work and activities.

DIAGNOSES

The patient was diagnosed as having discal cysts that compressed the left S1 based on findings of L-spine magnetic resonance imaging (MRI) performed at our hospital.

INTERVENTIONS

The patient received nonsurgical Korean Medicine treatment and after 24 days of treatment in the hospital, she underwent 16 additional treatments as an outpatient.

OUTCOMES

Spontaneous regression was confirmed in the L-spine MRI follow-up at 36 days and 99 days after the initial test, and the patient underwent once-a-week follow up to examine NRS, Oswestry Disability Index (ODI), EuroQol-5 Dimensions (EQ-5D), and fear-avoidance beliefs questionnaire (FABQ) after 4 weeks, and 2, 3, and 6-month follow-ups after that. The patient was discharged in a painless condition, and she was able to carry on for 5 months without increased pain.

LESSONS

Discal cysts are more rapid progress than disc herniation, it seems valid to attempt nonsurgical treatment. Epidemiologically, this is the first study to present the clinical epidemiological characteristics of discal cysts, it would provide valuable information to clinicians who treat and study discal cysts.

The Efficacy of Shinbaro for the Preventive Treatment of Migraine: A Pilot Study

Objective

To investigate the therapeutic potential and efficacy of Shinbaro, an herbal medication for inflammatory diseases and bone disorders, as a preventive treatment of migraine.

Methods

In this prospective, interventional, single-arm, pre-post study, 37 migraine patients took 600mg bid of Shinbaro for 12 weeks. At 4-week intervals, the migraine frequency and the rescue medications frequency were measured from each patient's headache diary. The modified Migraine Disability Assessment (MIDAS) questionnaires to assess migraine associated disabilities were also completed at each visit. The serum calcitonin gene-related peptide (CGRP) concentrations before and after 12 weeks of Shinbaro administration were compared.

Results

The monthly migraine frequency was significantly reduced from 20.5 days at baseline to 16.4 days at week 12 (P =0.003), and 22% of the participants showed ≥ 50% reduction. The frequency reduction was observed by week 4 (P =0.035) and continuously occurred through week 8 (P =0.001) and week 12 (P =0.003). The rescue medications frequency also decreased significantly from 17.4 days at baseline to 13.2 days at week 12 (P =0.035). Lastly, the serum CGRP concentration dropped from 434.6 pg/mL at baseline to 371.4 pg/mL at week 12, which was statistically significant (P <0.001).

Conclusions

Shinbaro demonstrated prophylactic effects in migraine patients, significantly reducing their mean migraine frequency, rescue medications frequency, and the serum CGRP concentration after 12 weeks of treatment. This study is registered in Clinical Research Information Service, Seoul National University Hospital Clinical Research Institute (IRB No. 1604-138-758).

Survey of integrative lumbar spinal stenosis treatment in Korean medicine doctors: preliminary data for clinical practice guidelines

BACKGROUND

Considering that large variations exist amongst practitioners in lumbar disorder management and the significant costs that lumbar disorders incur, determining clinical practice patterns to provide preliminary data for standardization should be given higher priority. Lumbar spinal stenosis (LSS) is commonly treated using integrative non-surgical methods by Korean medicine doctors (KMDs) in Korea, and this is the first study to assess current Korean medicine practice trends for LSS.

METHODS

A survey on KMD diagnosis, treatment, prognosis and decision-making in LSS treatment was developed in a 3-step procedure of preliminary drafting, revision based on extramural expert opinion, and final editing. The survey was conducted at the internal conference of a spine-specialty Korean medicine hospital on January 25th, 2015.

RESULTS

The response rate was high at 79.19% (n = 118/149). Participants replied that they treated 7.3 ± 6.8 LSS patients/day using a multimodal treatment method consisting of acupuncture, pharmacopuncture, herbal medicine, Chuna manipulation, and electroacupuncture. Acupuncture mainly used Ashi points and MSAT, and pharmacopuncture mainly Shinbaro solution. The most frequently prescribed herbal medicine was Chungpa-jun, and the most commonly applied Chuna techniques were sidelying lumbar extension dysfunction correction technique, and prone lumbosacral joint distraction method. Radiological findings were mainly referred to for diagnosis, and clinical symptoms, age, radiological findings, and medical history were regarded to be important for prognosis. Participants replied that 7.8 ± 3.3 weeks were required for 50% reduction in pain, and 16.1 ± 7.7 weeks for 80% reduction.

CONCLUSIONS

These results suggest that KMDs in Korea combine a conventional approach to LSS and a Korean medicine approach to low back pain for integration of empirical- and evidence-based diagnosis and treatment. The findings may contribute in bridging the divide between evidence and clinical practice guidelines for Korean medicine treatment of LSS and real-world clinical practice in future research.

Long-Term Course to Lumbar Disc Resorption Patients and Predictive Factors Associated with Disc Resorption

The long-term course to lumbar intervertebral disc herniation (LDH) patients receiving integrative Korean medicine treatment and predictive factors associated with disc resorption were investigated. LDH patients who received integrative Korean medicine treatment from February 2012 to December 2015 and were registered in the "longitudinal project for LDH on MRI" were included. Disc resorption amount was measured 3-dimensionally with disc degeneration and modic change levels on baseline and follow-up MRIs. Patient characteristics, Korean medicine use, pain, symptom recurrence, and satisfaction were assessed through medical records and phone surveys. Of 505 participants, 19 did not show disc resorption, while 486 did. A total of 220 displayed resorption rates of ≥50%. LDH volume at baseline was 1399.82 ± 594.96 mm³, and that on follow-up MRI was 734.37 ± 303.33 mm³, indicating a 47.5% decrease (p < 0.0001). Predictive factors for disc resorption were disc extrusion, Komori migration classification, and LDH amount. Approximately 68.4% did not experience symptom recurrence over the 51.86 ± 19.07-month follow-up, and 90.3% were satisfied with Korean medicine treatment. The majority of LDH patients who improved after integrative Korean medicine treatment showed disc resorption within 1 year with favorable long-term outcomes. Predictive factors for disc resorption should be duly considered for informed decision-making. This trial is registered with ClinicalTrials.gov NCT02841163.

Long-Term Course of Failed Back Surgery Syndrome (FBSS) Patients Receiving Integrative Korean Medicine Treatment: A 1 Year Prospective Observational Multicenter Study

Background

With increase of spine surgeries, failed back surgery syndrome (FBSS) prevalence is also rising. While complementary and alternative medicine (CAM) is commonly used for low back pain (LBP), there are no studies reporting use of integrative Korean medicine in FBSS patients.

Methods

Patients with pain continuing after back surgery or recurring within 1 year and visual analogue scale (VAS) of LBP or leg pain of ≥6 (total n = 120) were recruited at 2 hospital sites from November 2011 to September 2014. Weekly sessions of integrative Korean medicine treatment were conducted for 16 weeks (herbal medicine, acupuncture/electroacupuncture, pharmacopuncture/bee venom pharmacopuncture, and Chuna manual therapy) with additional follow-ups at 24 weeks and 1 year. Outcome measures included VAS of LBP and leg pain (primary outcome), Oswestry Disability Index (ODI), Short-Form 36 (SF-36), medical use, and patient global impression of change (PGIC).

Results

VAS of LBP and leg pain improved at 6 months (LBP from 6.1±2.0 at baseline to 2.9±2.3; and leg pain from 5.4±2.6 to 2.4±2.5, respectively). Eighty patients (66.7%) showed improvement of 50% or more in main pain of LBP or leg pain from baseline. Disability and quality of life also improved at 6 months (ODI from 41.3±12.3 at baseline to 23.6±13.6; and SF-36 from 42.8±14.5 to 62.7±16.8). At 1 year follow-up, conventional medical management use decreased, improvement in pain and disability was maintained, and 79.2% reported improvement of PGIC.

Conclusions

Despite limitations as an observational study, integrative Korean medicine treatment showed positive results in pain, function, and quality of life of FBSS patients.

Usage report of pharmacopuncture in musculoskeletal patients visiting Korean medicine hospitals and clinics in Korea

Background

Pharmacopuncture is a relatively new acupuncture therapy combining acupuncture with herbal medicine. While pharmacopuncture is applied extensively in Korean medicine treatment, there are no clinical reports regarding what types of pharmacopuncture are used for which diseases.

Methods

Data was extracted retrospectively from the electronic medical records of all inpatients and outpatients at 12 Korean medicine hospitals and clinics during the period of December 17, 2010 to October 2, 2014. Treatment patterns for acupuncture, electroacupuncture and pharmacopuncture were analyzed. Principle diagnosis codes, frequency of treatment, pharmacopuncture type and costs were investigated to assess pharmacopuncture use in clinical settings.

Results

During the study period, a total 33,415 inpatients and 373,755 outpatients visited the study sites, and most were musculoskeletal. Among inpatients and outpatients, 98.6 % and 77.6 % received pharmacopuncture, respectively. Administration rate of pharmacopuncture for the 10 most frequent principle diagnosis codes was 97.2–99.3 % in inpatients, and that for outpatients was 73.0–91.5 %. The average number of pharmacopuncture sessions in pharmacopuncture recipients was 8.2 ± 12.3 for outpatients and 25.8 ± 18.7 for inpatients. The mean total cost for pharmacopuncture per patient was $556.24 ± 174.62 among inpatients, and $149.16 ± 243.85 among outpatients. Estimated average cost per pharmacopuncture session was $23–24 for inpatients, and $17–18 for outpatients. Shinbaro1, bee venom, Hwangryunhaedok, and Shinbaro2 were the most frequently used pharmacopuncture types.

Conclusions

This is the first analysis of treatment patterns of pharmacopuncture in a large-scale Korean medicine hospital/clinic patient population. We verified patterns of pharmacopuncture use for musculoskeletal disease treatment in Korea, and use of pharmacopuncture varied depending on disease or symptom severity. These results are expected to contribute to future clinical study design and standardization of pharmacopuncture.

Long-Term Course of Alternative and Integrative Therapy for Lumbar Disc Herniation and Risk Factors for Surgery: A Prospective Observational 5-Year Follow-Up Study

STUDY DESIGN

Prospective observational 5-year study.

OBJECTIVE

To assess pain, functional disability, surgical status, and health care use of patients who actively selected complementary and alternative medicine treatment and risk factors for lumbar surgery.

SUMMARY OF BACKGROUND DATA

Controversy continues regarding difference in long-term outcomes of conservative and surgical treatment.

METHODS

We recruited 150 consecutive lumbar disc herniation patients with radiating pain (numeric rating scale ≥5) from November, 2006 at a Korean medicine hospital outpatient department, of which 128 patients completed 6 months of complementary and alternative medicine treatment (herbal medicine, acupuncture, bee-venom pharmacopuncture, and Chuna manipulation). Follow-up data was collected every year for 5 years.

RESULTS

We assessed surgical status in 105 patients (82%), of which 8 replied that they had received surgery. Ninety-two patients (72%) attended the 5-year follow-up. Visual analog scale of back pain which was 4.19 ± 2.60 at baseline improved after treatment, decreasing to 0.94 ± 1.13 at 6 months, and was maintained at 1.25 ± 1.81 at 5 years. Visual analog scale of leg pain decreased from 7.50 ± 1.32 to 0.94 ± 1.29 and was sustained at 0.98 ± 1.73. Participants reported less disability with Oswestry Disability Index scores decreasing from 41.50 ± 15.07 at baseline to 11.24 ± 10.44 at 6 months, which then declined further to 7.61 ± 9.82 at 5 years. SF-36 quality-of-life health survey scores also improved, increasing from 33.41 ± 12.67 at baseline to 66.04 ± 15.77 at 6 months, and reaching 75.43 ± 15.79 at 5 years. In assessment of satisfaction with current state, 20% replied "highly satisfied," 67% "satisfied," 10% "fairly satisfied," and 2% "dissatisfied." Patients with younger age, previous treatment for current pain episode, and higher levels of sensory impairment and pain in the lower extremities were at higher risk of lumbar surgery.

CONCLUSION

The long-term results of lumbar disc herniation patients receiving nonsurgical complementary and alternative medicine treatment were favorable and satisfaction rates were high.

LEVEL OF EVIDENCE

2.

Gastrointestinal safety and efficacy of long-term GCSB-5 use in patients with osteoarthritis: A 24-week, multicenter study

ETHNOPHARMACOLOGY RELEVANCE

A previous study indicated non-inferiority of GCSB-5 to celecoxib regarding efficacy and safety in treating OA; however, the gastrointestinal (GI) safety data was limited to 12 weeks. Accordingly, a longer term study with a larger number of patients was necessary to establish the GI safety of GCSB-5.

AIM OF STUDY

The primary goal was to determine the safety and efficacy of 24-week use of GCSB-5. The secondary goal was to compare the GI safety data of GCSB-5 with that of the previously reported Celecoxib Long-term Arthritis Safety Study (CLASS).

METHOD

This was a 24-week, multicenter, single-arm phase IV Study for the safety and efficacy of GCSB-5. A total of 761 patients were enrolled and 756 patients received at least one dose of GCSB-5. Among them, 629 patients (82.7%) completed the 24 week follow up. The primary goal was to determine the safety and efficacy of GCSB-5 for 24 weeks. The secondary goal was to compare the GI safety data of GCSB-5 with that of the previously reported Celecoxib Long-term Arthritis Safety Study (CLASS).

RESULTS

The incidence of GI disorders of GCSB-5 was 23.7%. The annual rate of perforation, ulcer obstruction, or bleeding (PUB) incidence was 0.0%. The drop-out rate due to GI disorders following GCSB-5 use was 4.8%. Compared to celecoxib data from CLASS, the incidence of GI disorders (23.7% vs. 31.4%, p<0.001), annual rate of PUB and gastroduodenal ulcers (0.0% vs 2.2%, p=0.004), and drop-out rate due to GI disorders following GCSB-5 use were significantly low (4.8% vs 8.7%, p<0.001). Efficacy was proven by significant improvements in Western Ontario McMaster Questionnaire (WOMAC) scale, Korean Knee Score (KKS), 100-mm pain visual analogue scale (VAS), and physician's global assessments of patient's response to therapy (PGART).

CONCLUSIONS

The safety and efficacy profile of GCSB-5 are comparable to celecoxib. These results indicate GCSB-5 is safe for a long-term treatment of knee OA patients.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT01604239).

Long term follow-up of cervical intervertebral disc herniation inpatients treated with integrated complementary and alternative medicine: a prospective case series observational study

Background

Symptomatic cervical intervertebral disc herniation (IDH) presenting as neck pain accompanied by arm pain is a common affliction whose prevalence continues to rise, and is a frequent reason for integrative inpatient care using complementary and alternative medicine (CAM) in Korea. However, studies on its long term effects are scarce.

Methods

A total 165 patients with cervical IDH admitted between January 2011 and September 2014 to a hospital that provides conventional and Korean medicine integrative treatment with CAM as the main modality were observed in a prospective observational study. Patients underwent CAM treatment administered by Korean medicine doctors (KMDs) in accordance with a predetermined protocol for the length of hospital stay, and additional conventional treatment by medical doctors (MDs) as referred by KMDs. Short term outcomes were assessed at discharge and long term follow-ups were conducted through phone interviews after discharge. Numeric rating scale (NRS) of neck and radiating arm pain, neck disability index (NDI), 5-point patient global impression of change (PGIC), and factors influencing long term satisfaction rates in PGIC were assessed.

Results

Of 165 patients who received inpatient treatment 20.8 ± 11.2 days, 117 completed the long term follow-up up at 625.36 ± 196.7 days post-admission. Difference in NRS between admission and discharge in the long term follow-up group (n = 117) was 2.71 (95 % CI, 2.33, 3.09) for neck pain, 2.33 (95 % CI, 1.9, 2.77) for arm pain, and that of NDI 14.6 (95 % CI, 11.89, 17.32), and corresponding scores in the non-long term follow-up group (n = 48) were 2.83 (95 % CI, 2.22, 3.45) for neck pain, 2.48 (95 % CI, 1.84, 3.12) for arm pain, and that of NDI was 14.86 (95 % CI, 10.41, 19.3). Difference in long term NRS of neck pain and arm pain from baseline was 3.15 (95 % CI, 2.67, 3.64), and 2.64 (95 % CI, 1.99, 3.29), respectively. PGIC was reported to be “satisfactory” or higher in 79.5 % of patients at long term follow-up.

Conclusions

Though the observational nature of this study limits us from drawing a more decisive conclusion, these results suggest that integrative treatment focused on CAM in cervical IDH inpatients may achieve favorable results in pain and functional improvement.

Trial registration

ClinicalTrials.gov Identifier: NCT02257723. Registered October 2, 2014.

A survey among Korea Medicine doctors (KMDs) in Korea on patterns of integrative Korean Medicine practice for lumbar intervertebral disc displacement: Preliminary research for clinical practice guidelines

Background

Patients seek Korean Medicine (KM) treatment for a broad range of complaints in Korea, but predominantly for musculoskeletal disorders. We investigated lumbar Intervertebral Disc Displacement (IDD) practice patterns of Korean Medicine doctors (KMDs) within a hospital/clinic network specializing in KM treatment of spinal disorders through survey of diagnosis and treatment methods.

Methods

Questionnaires on clinical practice patterns of KM treatment for lumbar IDD were distributed to 149 KMDs on January 25th, 2015. The questionnaire included items on sociodemographic characteristics, clinical practice patterns, and preferred method of lumbar IDD diagnosis and treatment. KMDs were asked to grade each treatment method for absolute and relative importance in treatment and prognosis, and safety.

Results

A total 79.19 % KMDs (n = 118/149) completed the survey, and results showed that integrative care mainly consisting of acupuncture, herbal medicine, Chuna manipulation, and pharmacopuncture was administered to IDD patients. The participant KMDs largely relied on radiological findings (MRI and X-ray) for diagnosis. ‘Eight principle pattern identification’, ‘Qi and Blood syndrome differentiation’ and ‘Meridian system syndrome differentiation’ theories were generally used for KM syndrome differentiation. The most frequently prescribed herbal medication was Chungpa-jun, and most commonly used Chuna technique was ‘sidelying lumbar extension displacement treatment’. IDD patients received 1.9 ± 0.3 treatment sessions/week, and KMDs estimated that an average 9.6 ± 3.5 weeks were needed for 80 % pain relief.

Conclusions

This is the first study to investigate expert opinion on KM treatment of IDD. Further randomized controlled trials and clinical guidelines based on clinical practice patterns of KM are called for.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-015-0956-1) contains supplementary material, which is available to authorized users.

A commercialized dietary supplement alleviates joint pain in community adults: a double-blind, placebo-controlled community trial

BACKGROUND

The purpose of this study was to assess the effect of 8-weeks ingestion of a commercialized joint pain dietary supplement (Instaflex™ Joint Support, Direct Digital, Charlotte, NC) compared to placebo on joint pain, stiffness, and function in adults with self-reported joint pain. Instaflex™ is a joint pain supplement containing glucosamine sulfate, methylsufonlylmethane (MSM), white willow bark extract (15% salicin), ginger root concentrate, boswella serrata extract (65% boswellic acid), turmeric root extract, cayenne, and hyaluronic acid.

METHODS

Subjects included 100 men and women, ages 50-75 years, with a history (>3 months) of joint pain, and were randomized to Instaflex™ or placebo (3 colored gel capsules per day for 8 weeks, double-blind administration). Subjects agreed to avoid the use of non-steroidal anti-inflammatory drugs (NSAID) and all other medications and supplements targeted for joint pain. Primary outcome measures were obtained pre- and post-study and included joint pain severity, stiffness, and function (Western Ontario and McMaster Universities [WOMAC]), and secondary outcome measures included health-related quality of life (Short Form 36 or SF-36), systemic inflammation (serum C-reactive protein and 9 plasma cytokines), and physical function (6-minute walk test). Joint pain symptom severity was assessed bi-weekly using a 12-point Likert visual scale (12-VS).

RESULTS

Joint pain severity was significantly reduced in Instaflex™ compared to placebo (8-week WOMAC, ↓37% versus ↓16%, respectively, interaction effect P = 0.025), with group differences using the 12-VS emerging by week 4 of the study (interaction effect, P = 0.0125). Improvements in ability to perform daily activities and stiffness scores in Instaflex™ compared to placebo were most evident for the 74% of subjects reporting knee pain (8-week WOMAC function score, ↓39% versus ↓14%, respectively, interaction effect P = 0.027; stiffness score, ↓30% versus ↓12%, respectively, interaction effect P = 0.081). Patterns of change in SF-36, systemic inflammation biomarkers, and the 6-minute walk test did not differ significantly between groups during the 8-week study

CONCLUSIONS

Results from this randomized, double blind, placebo-controlled community trial support the use of the Instaflex™ dietary supplement in alleviating joint pain severity in middle-aged and older adults, with mitigation of difficulty performing daily activities most apparent in subjects with knee pain.