A Closer Look At Homeopathic Modalities For Joint Pain

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Podiatric physicians and surgeons have a wide array of modalities to choose from when it comes to the treatment of chronic joint disease and the pain related to these conditions. These modalities include oral analgesics that are opioid-based, nonsteroidal antiinflammatories (NSAIDs) and various forms of glucocorticoids that patients can take both orally and in injection form. There are also various forms of injectable hyaluronic acid to rehydrate and cushion the joint.

Due to the chronic nature of the disease involving the joints, efficacy and side effects are important considerations when choosing a suitable long-term therapy. [3]In particular, NSAIDs, which are the most commonly utilized drug group, have well-documented histories of adverse reactions that include abdominal pain, diarrhea, nausea and more serious side effects of bronchospasm, gastrointestinal bleeding and ulcers.

Most recently, COX-2 inhibitors have demonstrated severe cardiovascular adverse reactions. This resulted in the FDA removing a couple of products from the market.^1-3

Nonsteroidal antiinflammatory drugs exert their antiinflammatory, anti-pyretic and analgesic actions by inhibiting the synthesis of prostaglandins by cyclooxygenase COX-1 and COX-2. The COX-2 form is induced by pro-inflammatory agents such as cytokines, bacterial stimuli and tumor promoting factors.⁴ The preferential inhibition of COX-1 by traditional NSAIDs is thought to be responsible for their gastrotoxic effects by affecting the regulation of homeostatic functions in the gastric mucosa.

Researchers are currently studying a new generation of antiinflammatory drugs that specifically target COX-2 induced prostaglandin production without influencing the homeostatic functions. However, while COX-2 medications may reduce the risk of gastropathy, recent research revealed cardiovascular events with long-term use and adverse renal effects like sodium, potassium and water retention as well as decreases in renal function similar to those of nonselective NSAIDs.^5,6 

In addition, prostaglandin synthesis by NSAIDs is also associated with an increased production of leukotrienes by 5-lipooxygenase. Since the COX isoenzymes and 5-LOX share the same substrate, arachidonic acid, the COX pathway can lead to a reduction of leukotrienes by 5-LOX due to increased substrate availability.

Leukotrienes contribute to inflammatory processes and are implicated in the development of gastrointestinal ulcers.⁷ Leukotrienes are also potent bronchoconstrictors that contribute to the NSAID-induced “aspirin asthma” in susceptible patients.⁸ 

Researchers have also reported in the literature that long-term NSAID use may exacerbate degenerative changes in the cartilage.^9,10

Looking For Alternatives To NSAIDs For Chronic Joint Pain

Having seen these adverse reactions in my own patients when I utilized long-term NSAID therapy and/or steroids for long-term care of painful joints in the foot and ankle, I looked for a safer alternative for long-term management of chronic joint pain.

After doing an extensive literature review of alternative therapies for chronic joint pain management several years ago, it was clear that homeopathic injections specific for joint pain are uniformly efficacious and have very little adverse reactions for patients with arthritis. I have been using homeopathic injections in my office for several years and have found that patients tend to have greater acceptance of this modality for the treatment of their joint pain as opposed to NSAIDs and steroids. Most of the lay public have now heard about or understand the adverse sequelae to long-term NSAID and steroid use, and are seeking alternative therapies.

Homeopathic Combination Injections: Can They Have An Impact?

Researchers have assessed a German homeopathic combination injection and compared it to NSAIDs in regard to efficacy in the reduction of joint pain for patients with degenerative joint disease. Several head-to-head studies have compared these two modalities and they have found uniform improvement in patient symptoms^.11

Since I was trained allopathically, I thought it necessary to know the mechanism of action of this homeopathic medicine in regard to treating chronic joint pain. Several authors have demonstrated the dual inhibition of 5-lipoxygenase/cyclooxygenase by a reconstituted homeopathic medicine. These articles also explained the possible mechanism for the clinical efficacy of this medication and noted its favorable gastrointestinal tolerability over the use of traditional NSAIDs.

Produced in Germany, Zeel-T (Heel, Inc.), the homeopathic medicine used in these studies, contains 15 homeopathic medicines in a diluted form consistent with standard homeopathic principles. The individual ingredients are formulated to work synergistically to show distinct inhibitory effects on the production of LTB4 by 5-lipoxygenase and on the synthesis of PGE-2 by COX-1 and COX-2 enzymes.¹²

I have used the injectable form of this antiinflammatory mixed with either bupivacaine (Marcaine) or lidocaine for the treatment of degenerative joint disease in the first metatarsophalangeal joint (first MPJ), subtalar arthritis and other degenerative joint disease pathology in the lower extremity. It also works well for psoriatic arthritis and rheumatoid arthritis.

Zeel comes in 2 mL glass ampoules and I mixed this with 1 or 2 cc 0.5% bupivacaine or 2% lidocaine plain, depending upon the size of the joint and whether I am going to perform a periarticular injection or an intraarticular injection. Since the homeopathic medicine is isotonic in nature, there is very little pain with the injection if one uses the modality without an anesthetic. Patients tolerate these injections very well.

When it comes to first MPJ degenerative changes with chronic pain, I perform an intraarticular injection of 1 cc of the Zeel medication. If there is acute pain associated with the joint, I will perform a periarticular injection of the medication and mix in a local anesthetic in the syringe.

There is no precipitation or flocculation that occurs when mixing Zeel-T with lidocaine or bupivacaine. One can give these injections weekly without any danger of adverse reactions or soft tissue instability that one may see with steroid injections.

I usually follow up with these patients by prescribing an oral form of the homeopathic medicine (Zeel oral tablets) and a topical cream (Zeel ointment), which have similar homeopathic constituents that are in the injectable form.

One can give this homeopathic medicine concomitantly with NSAIDs without any additive adverse reactions involving the gastrointestinal or cardiovascular or renal systems. A study by Makio demonstrated that the combined allopathic and homeopathic treatment utilizing Zeel-T and diclofenac produced greater and longer lasting improvement in symptoms. Makio noted that the combination of these modalities proved especially effective in treating periarthritis and mild to moderate synovitis in 80 patients with advanced osteoarthritis of the knee.¹¹

How Traumeel Can Be Beneficial For Lower Extremity Pain

Another homeopathic injectable medication that I use on a regular basis is called Traumeel (Heel, Inc.). [4]It is a combination of 14 homeopathic medicines in a synergistic ratio. Physicians can use this modality for the treatment of arthritic pain, inflammation, bruising and muscular pain. Traumeel is also excellent for the treatment of sports injuries such as tendonitis, sprains, strains and contusions.

I will sometimes use Traumeel injectable in combination with Zeel-T for acutely swollen and painful arthritic joints. Why do I do this? The antiinflammatory and analgesic component of the Traumeel is geared more toward acute inflammation whereas the Zeel-T is geared more toward chronic inflammation and degenerative changes within the joint.

Traumeel is an excellent stand-alone homeopathic medicine for the treatment of plantar fasciitis, tendonitis, bursitis and for the prevention of postoperative bruising and swelling.

I utilize both the Traumeel injectable and oral tablets preoperatively and postoperatively for various podiatric surgical procedures that I perform. I have noticed a dramatic reduction in postoperative pain and swelling. I have also noticed a reduced need for opioid narcotics postoperatively when I prep the patients with Traumeel orally and then inject the Traumeel at the end of the procedure in the operating room.

Keeping the patient’s preoperative weight in mind, I generally have the patient take one Traumeel tablet four times a day seven to 10 days prior to surgery. It is important to have the patient dissolve the tablet slowly in the mouth sublingually, away from food, to get maximum tissue absorption. I carry this through to the day of surgery. Postoperatively, I recommend one tablet TID sublingual for 21 days to be taken away from food.PT12Injection1.jpgsubendsubsubendsub**
After having used these homeopathic injections, oral homeopathic medications and topical creams for a number of years, I have found that they are very efficacious and have a very low adverse reaction profile. Homeopathic medicines work well with standard medical protocols such as NSAIDs, physical therapy modalities, orthotics and splints.
 
I highly recommend the consideration of these homeopathic medications as additional modalities in the treatment of many common foot problems that we see in our office. I also recommend the use of Traumeel for the more acute symptoms that occur as a result of injury or surgery.

In my clinical experience, the inclusion of homeopathic Traumeel in the treatment of foot and ankle fractures has significantly reduced the amount of swelling, bruising and pain without the adverse side effects of high doses of NSAIDs or the addictive properties of opioids.

In my perspective, there is sufficient scientific research with good parameters that demonstrates the efficacy and safety of these homeopathic medications so we can prescribe them with confidence to our patients.

Editor’s note: For related articles, see “Alternative Therapies For Chronic Joint Pain” [5] in the August 2005 issue of Podiatry Today.

References:

1. Berges-Gimenco MP, Simon RA, Stevenson DD. The natural history and clinical characteristics of aspirin exacerbated respiratory disease. Annals Allergy Asthma Immunology 89:474-78, 2002.
2. Bakr M, Waller DG. COX-2 inhibitors and the cardiovascular system: is there a class effect? Br J Cardio 12(5):387-391, 2005.
3. Kimmey MB. NSAIDs, ulcers and prostaglandins. J Rheumatol supplement 36:68-73, 1992.
4. Vane JR, Botting MR. Anti-inflammatory drugs and their make mechanism of action. Inflammatory Research 47 supplement. 2: S78-87, 1998.
5. Breyer MD, Harris RC. Cyclooxygenase 2 and the kidney. Cur Opin Nephrology Hypertension 10:89-98, 2001.
6. Ahmad SR, Kortpeter C, Brinker A, Chen M, Beitz J. Renal failure associated with the use of celecoxib and rofecoxib. Drug Safety 25(7):537-44, 2002.
7. Hudson N, Balsitis M, Everett S, Hawkey CJ. Enhance gastric mucosal leukotriene B-4 synthesis in patients taking nonsteroidal anti-inflammatory drugs. Gut 34:742-7, 1993.
8. Szczeklik A, Sanak M, et. al. Aspirin intolerance and the cyclooxygenase-leukotriene pathways. Curr Opin Pulmonary Med 10(1):51-56, 2004.
9. Herman JH, Hess EV. Therapeutic impasse and osteoarthritis. Br J Rheumatology 33(12):1098-1100, 1994.
10. Huskisson EC, Berry H, Gishen P, et al. Effects of anti-inflammatory drugs on the progression of osteoarthritis of the knee. LINK Study Longitudinal Investigation on Nonsteroidal Anti-inflammatory Drugs in Knee Osteoarthritis. J Rheumatol 22 (10):1941-6, 1995.
11. Maiko, OJ. Homoopathische Therapie der Gonarthrose mit Zeel T. Biol Med 31(2):68-74, 2002.
12. Jaggi R, Wurgler U, Weiser M. Dual inhibition of 5-lipoxygenase/cyclooxygenase by a reconstituted homeopathic remedy; possible explanation for clinical efficacy and favorable gastrointestinal tolerability. Inflammation Research. 53: 150-157, 2004.