Nutritional Approaches for Musculoskeletal Pain and Inflammation: What the Science Says
Clinical Guidelines, Scientific Literature, Info for Patients:
Nutritional Approaches for Musculoskeletal Pain and Inflammation
Willow Bark (Salix alba)
Willow bark has been used for centuries as a treatment for pain, headache, and inflammatory conditions such as bursitis and tendinitis. The bark of white willow contains salicin, the chemical that was used to develop aspirin. Despite its long history of use, only a few small clinical trials have been conducted that support the use of willow bark extracts in chronic low-back pain and osteoarthritis.
What Does the Research Show?
- A 2019 review evaluated current research on dietary ingredients for chronic musculoskeletal pain to inform decisions for practice and self-care, specifically for Special Operations Forces personnel in the U.S. military. Nineteen eligible dietary ingredients were assessed for quality, efficacy, and safety. Recommendations were made against the use of willow bark extract and several other supplements to mitigate chronic musculoskeletal pain.
- A 2015 review of willow bark extract concluded that based on available evidence in conjunction with its anecdotal use for hundreds of years, the findings suggest that willow bark extract is effective as an analgesic and anti-inflammatory.
- A 2014 Cochrane review of 2 clinical trials involving 261 participants found moderate quality evidence that daily doses of white willow bark are probably better than placebo for short-term improvements in low-back pain and may reduce the use of rescue medication.
- A 2019 U.S. Pharmacopeia safety review of willow bark found that no serious adverse events were reported from trials of willow bark extracts delivering 120 to 240 mg salicin (the purported active constituent) daily for up to 8 weeks. It is important to note that the trials were conducted in adults only, and none involved children, or pregnant or breastfeeding women. The most common adverse effects associated with willow bark are gastrointestinal, and a few allergic reactions were also reported. The review also concluded that there is a risk of increased bleeding in vulnerable individuals, salicylates cross the placenta and are eliminated slowly in newborns, some persons are sensitive or allergic to aspirin, and children are at risk of Reye's syndrome. Concurrent use with other salicylate-containing medicines increases these risks.
- Children, people who are pregnant or nursing, or people with known sensitivity to aspirin should not use willow bark.
Omega-3 Fatty Acids
There is some evidence that omega-3 fatty acids may provide a modest benefit for symptoms of rheumatoid arthritis.
What Does the Research Show?
- A 2018 systematic review and meta-analysis of 20 randomized controlled trials involving a total of 1,252 participants with rheumatoid arthritis (RA) found that despite the evidence of overall low quality of studies included in the analysis, consumption of omega-3 fatty acids was found to significantly improve 8 RA disease-activity-related markers. However, among five proinflammatory markers evaluated, only leukotriene B4 was found to be reduced.
- A 2021 systematic review of 31 studies conducted in 16 countries measured the effects of eicosapentaenoic acid (EPA) and/or docosahexaenoic acid (DHA) supplementation on circulating levels of leptin and adiponectin. The reviewers found that 18 studies reported lower leptin and/or higher adiponectin levels with EPA plus DHA supplementation compared with placebo (9 reported statistically significant differences); however, doses, supplementation duration, and population characteristics varied across studies.
- A 2015 randomized controlled trial conducted in overweight/obese pregnant women who received DHA plus EPA or placebo twice a day from week 10–16 to term found that supplementation with omega-3 fatty acids for more than 25 weeks reduced inflammation in maternal adipose and the placental tissue.
- Omega-3 fatty acid supplements are generally safe and well-tolerated. When side effects do occur, they typically consist of minor gastrointestinal symptoms and fishy aftertaste.
- There is some concern that omega-3 supplements may extend bleeding time. The risk appears to be minimal; however, omega-3 supplements should never be used in patients who take drugs that affect platelet function. It is important to discuss any potential herb-drug interactions with patients if they are considering using omega-3 fatty acids.
- It is uncertain whether people with fish or shellfish allergies can safely consume fish oil supplements and should not be used in such patients.
Devil’s Claw (Harpagophytum)
Devil’s claw is an herb native to Africa. Devil’s claw is sometimes used for arthritis, gout, myalgia, tendonitis, and other conditions. There is some limited evidence that devil’s claw may provide modest improvements in low-back pain over the short term. There is some moderate evidence that devil’s claw is beneficial for osteoarthritis of the spine, hip, and knee.
What Does the Research Show?
- A 2019 review evaluated current research on dietary ingredients for chronic musculoskeletal pain to inform decisions for practice and self-care, specifically for Special Operations Forces personnel in the U.S. military. Nineteen eligible dietary ingredients were assessed for quality, efficacy, and safety. Recommendations were made against the use of devil's claw and several other supplements to mitigate chronic musculoskeletal pain.
- A 2014 Cochrane review of 2 clinical trials involving 315 participants found low-quality evidence that daily doses of devil’s claw may be better than placebo for short-term improvements in low-back pain and may reduce use of rescue medication.
- A 2008 review of dietary supplements for osteoarthritis concluded that there is insufficient reliable evidence of long-term safety or effectiveness of devil’s claw for this condition.
- A 2008 systematic review of 28 clinical trials on the safety of devil’s claw for osteoarthritis and low-back pain concluded that although the incidence of adverse events during treatment with devil’s claw is low, more long-term safety data are needed.
- Devil’s claw may affect heart rate and blood pressure and may be harmful in people with heart disease or circulatory system disorders.
- Devil’s claw may lower blood glucose levels, so people with diabetes should monitor blood glucose levels closely.
- People with gallstones or peptic ulcer disease should avoid using devil’s claw.
Ginger (Zingiber officinale)
Historically, ginger has been used in Asian medicine to treat stomach aches, nausea, and diarrhea. Today, ginger is used as a folk or traditional remedy for postsurgery nausea; nausea caused by motion, chemotherapy, and pregnancy; rheumatoid arthritis; osteoarthritis; and joint and muscle pain. Based on available evidence, it is unclear whether supplementation of ginger is beneficial in treating rheumatoid arthritis, osteoarthritis, or joint and muscle pain.
What Does the Research Show?
- A 2020 systematic review and meta-analysis of seven trials found insufficient evidence to support the use of oral ginger compared with placebo in the pain relief and function improvement in patients with knee osteoarthritis.
- A 2019 review evaluated current research on dietary ingredients for chronic musculoskeletal pain to inform decisions for practice and self-care, specifically for Special Operations Forces personnel in the U.S. military. Nineteen eligible dietary ingredients were assessed for quality, efficacy, and safety. Conditional evidence-based recommendations were made for the use of ginger, as well as several other dietary supplements. In these cases, desirable effects outweighed undesirable effects, but there was uncertainty about the trade-offs, either because the evidence was low quality or because benefits and downsides were closely balanced.
- A 2010 study of a total of 74 participants examined the effects of ginger on muscle pain and inflammation caused by eccentric exercise. The study found that daily consumption of raw and heat-treated ginger resulted in moderate-to-large reductions in muscle pain following exercise-induced muscle injury.
- Few adverse reactions are linked to ginger when taken in small doses. Minor side effects most often reported are gas, bloating, heartburn, and nausea; however, these effects are most often associated with powdered ginger.
Thunder God Vine (Tripterygium wilfordii)
Thunder god vine is a perennial vine native to China, Japan, and Korea. It has been used in China for health purposes for more than 400 years. In traditional Chinese medicine, it has been used for conditions involving inflammation or overactivity of the immune system. There is some evidence that thunder god vine may reduce some symptoms of rheumatoid arthritis (RA); however, thunder god vine may be associated with some serious adverse side effects.
What Does the Research Show?
- A 2011 Cochrane review of three studies that compared thunder god vine with sulfasalazine for rheumatoid arthritis, concluded that thunder god vine may reduce some RA symptoms, but may be associated with some serious adverse side effects.
- Another 2011 systematic review of complementary health approaches for the management of RA examined three studies on thunder god vine and found positive effects. However, there was no consistent evidence for any of the reviewed substances to suggest that they were efficacious.
- Thunder god vine can cause severe adverse side effects and can be poisonous if it is not carefully extracted from the skinned root. Other parts of the plant—including the leaves, flowers, and skin of the root—are highly poisonous and can cause death.
- A number of participants in one study experienced gastrointestinal adverse effects, as well as upper respiratory tract infections. (The rate of adverse effects was similar in the thunder god vine and sulfasalazine groups.)
- Thunder god vine can also cause hair loss, headache, menstrual changes, and skin rash.
- There are no consistent, high-quality thunder god vine products being manufactured in the United States. Preparations of thunder god vine made outside the United States can sometimes be obtained, but it is not possible to verify whether they are safe and effective.
- Thunder god vine has been found to decrease bone mineral density in women who take the herb for 5 years or longer.
- Thunder god vine contains chemicals that might decrease male fertility by changing sperm.
Turmeric (Curcuma longa)
Turmeric has a long history of use in Ayurvedic medicine for the treatment of inflammatory disorders. Curcumin, a chemical extracted from turmeric, is often used as a remedy for the treatment and prevention of inflammatory diseases. Preliminary findings from laboratory research suggest that curcumin, a chemical found in turmeric, may have anti-inflammatory properties, but in spite of its long history of use for inflammatory disorders, there is insufficient evidence to support the use of turmeric supplementation for these disorders.
What Does the Research Show?
- A 2021 systematic review of 10 studies involving a total of 1,287 participants found that compared with placebo, turmeric may have a beneficial effect, similar to that of nonsteroidal anti-inflammatory drugs, on knee osteoarthritis pain and function. However, the reviewers noted that variables such as optimal dosing, frequency, and formulation remain unclear at this time.
- A 2021 review found several studies highlighting the beneficial effects of turmeric and curcumin in different patent formulations for treating and preventing inflammatory and painful disorders including inflammatory bowel diseases, osteoarthritis, skin, and oral inflammation, as well as neuropathic pain. However, the reviewers noted that because of inadequate clinical trials, further high-quality studies are needed to firmly establish the clinical efficacy of this plant.
- A 2019 review evaluated current research on dietary ingredients for chronic musculoskeletal pain to inform decisions for practice and self-care, specifically for Special Operations Forces personnel in the U.S. military. Nineteen eligible dietary ingredients were assessed for quality, efficacy, and safety. Conditional evidence-based recommendations were made for the use of turmeric, as well as several other dietary supplements. In these cases, desirable effects outweighed undesirable effects, but there was uncertainty about the trade-offs, either because the evidence was low quality or because benefits and downsides were closely balanced.
- A 2020 systematic review of 11 studies found that the use of curcumin reduces the subjective perception of the intensity of muscle pain; reduces exercise-induced muscle damage through the decrease of creatine kinase; increases muscle performance; has an anti-inflammatory effect by modulating the pro-inflammatory cytokines, such as TNF-α, IL-6, and IL-8; and may have a slight antioxidant effect.
- Turmeric is considered safe for most adults, but high doses or long-term use may cause indigestion, nausea, or diarrhea.
Bromelain (pineapple plant)
Bromelain is a mixture of enzymes found in the pineapple plant. Bromelain is often used as a dietary supplement for nasal swelling and inflammation, osteoarthritis, cancer, poor digestion, and muscle soreness. In spite of its use, the exact mechanism of action remains poorly understood. There is some evidence that bromelain may be useful as adjunctive therapy to help improve acute nasal and sinus inflammation, but there is insufficient evidence as to whether bromelain has any beneficial effects on other inflammatory conditions.
What Does the Research Show?
- A 2019 systematic review and meta-analysis of six randomized controlled trials evaluated whether bromelain may decrease trismus, pain, and facial swelling in patients undergoing impacted third molar surgery. The findings suggested that bromelain appears to be effective for decreasing facial swelling in the early and late stages after surgery. Bromelain alleviated postoperative pain 7 days after surgery, but there was no significant difference in pain levels at the early stage. For trismus, analyses showed that bromelain had no apparent effect on early or late trismus.
- A 2014 prospective, placebo-controlled trial of 34 patients evaluated the anti-inflammatory and analgesic effect of bromelain in the postoperative after extraction of impacted lower molars. The study found no statistically significant differences between the bromelain and placebo groups, a trend toward less inflammation, and improved oral aperture was observed in the bromelain group, compared to placebo.
- Findings from a 2006 systematic review of three randomized controlled trials suggest that bromelain is helpful in relieving symptoms of acute nasal and sinus inflammation when used as adjunctive therapy with standard medications such as antihistamines, analgesics, and/or antibiotics.
- There have been some reports of gastrointestinal problems, increased heart rate, and menstrual problems in people who have taken oral bromelain.
- Allergic reactions may occur in individuals who are sensitive or allergic to pineapples or who may have other allergies.
- Araya-Quintanilla F, Gutierrez-Espinoza H, Munoz-Yanez MJ, et al. Effectiveness of ginger on pain and function in knee osteoarthritis: A PRISMA systematic review and meta-analysis. Pain Physician. 2020;23(2):E151-E161.
- Black CD, Herring MP, Hurley DJ, et al. Ginger (Zingiber officinale) reduces muscle pain caused by eccentric exercise. The Journal of Pain. 2010;11(9):894-903.
- Boyd C, Crawford C, Berry K, et al. Conditional recommendations for specific dietary ingredients as an approach to chronic musculoskeletal pain: evidence-based decision aid for health care providers, participants, and policy makers. Pain Medicine. 2019;20(7):1430-1448.
- Brien S, Lewith G, Walker A, et al. Bromelain as a treatment for osteoarthritis: a review of clinical studies. Evidence-Based Complementary and Alternative Medicine: eCAM. 2004;1(3):251-257.
- Cameron M, Gagnier JJ, Chrubasik S. Herbal therapy for treating rheumatoid arthritis. Cochrane Database of Systematic Reviews. 2011;(2):CD002948.
- Chantre P, Cappelaere A, Leblan D, et al. Efficacy and tolerance of Harpagophytum procumbens versus diacerhein in treatment of osteoarthritis. Phytomedicine. 2000;7(3):177-183.
- Crawford C, Boyd C, Paat CF, et al. Dietary ingredients as an alternative approach for mitigating chronic musculoskeletal pain: evidence-based recommendations for practice and research in the military. Pain Medicine. 2019;20(6):1236-1247.
- de la Barrera-Núñez MC, Yáñez-Vico R-M, Batista-Cruzado A, et al. Prospective double-blind clinical trial evaluating the effectiveness of bromelain in the third molar extraction postoperative period. Medicina Oral, Patologia Oral y Cirugia Bucal. 2014;19(2):e157-162.
- Di Lorenzo C, Dell’Agli M, Badea M, et al. Plant food supplements with anti-inflammatory properties: a systematic review (II). Critical Reviews in Food Science and Nutrition. 2013;53(5):507-516.
- Fernández-Lázaro D, Mielgo-Ayuso J, Calvo JS, et al. Modulation of exercise-induced muscle damage, inflammation, and oxidative markers by curcumin supplementation in a physically active population: a systematic review. Nutrients. 2020;12(2):501.
- Gagnier JJ, Chrubasik S, Manheimer E. Harpgophytum procumbens for osteoarthritis and low back pain: a systematic review. BMC Complementary and Alternative Medicine. 2004;4:13.
- Gioxari A, Kaliora AC, Marantidou F, et al. Intake of ω-3 polyunsaturated fatty acids in patients with rheumatoid arthritis: a systematic review and meta-analysis. Nutrition. 2018;45:114-124.e4.
- Gregory PJ, Sperry M, Wilson AF. Dietary supplements for osteoarthritis. Am Fam Physician. 2008;77(2):177–184.
- Guo R, Canter PH, Ernst E. Herbal medicines for the treatment of rhinosinusitis: a systematic review. Otolaryngology—Head and Neck Surgery. 2006;135(4):496-506.
- Haghiac M, Yang X-H, Presley L, et al. Dietary omega-3 fatty acid supplementation reduces inflammation in obese pregnant women: a randomized double-blind controlled clinical trial. PLoS One. 2015;10(9):e0137309.
- Liu S, Zhao H, Wang Y, et al. Oral bromelain for the control of facial swelling, trismus, and pain after mandibular third molar surgery: a systematic review and meta-analysis. Journal of Oral and Maxillofacial Surgery. 2019;77(8):1566-1574.
- Macfarlane GJ, El-Metwally A, De Silva V, et al. Evidence for the efficacy of complementary and alternative medicines in the management of rheumatoid arthritis: a systematic review. Rheumatology. 2011;50(9):1672-1683.
- Madhu K, Chanda K, Saji MJ. Safety and efficacy of Curcuma longa extract in the treatment of painful knee osteoarthritis: a randomized placebo-controlled trial. Inflammopharmacology. 2013;21(2):129-136.
- Miles EA, Calder PC. Influence of marine n-3 polyunsaturated fatty acids on immune function and a systematic review of their effects on clinical outcomes in rheumatoid arthritis. The British Journal of Nutrition. 2012;107(Suppl 2):S171-184.
- Oketch-Rabah HA, Marles RJ, Jordan SA, et al. United States Pharmacopeia safety review of willow bark. Planta Medica. 2019;85(16):1192-1202.
- Oltean H, Robbins C, van Tulder MW, et al. Herbal medicine for low-back pain. Cochrane Database of Systematic Reviews. 2014;(12):CD004504.
- Paultre K, Cade W, Hernandez D, et al. Therapeutic effects of turmeric or curcumin extract on pain and function for individuals with knee osteoarthritis: a systematic review. BMJ Open Sport & Exercise Medicine. 2021;7(1):e000935.
- Peddada KV, Peddada KV, Shukla SK, et al. Role of curcumin in common musculoskeletal disorders: a review of current laboratory, translational, and clinical data. Orthopaedic Surgery. 2015;7(3):222-231.
- Rausch J, Gillespie S, Orchard T, et al. Systematic review of marine-derived omega-3 fatty acid supplementation effects on leptin, adiponectin, and the leptin-to-adiponectin ratio. Nutrition Research. 2021;85:135-152.
- Razavi BM, Rahbardar MG, Hosseinzadeh H. A review of therapeutic potentials of turmeric (Curcuma longa) and its active constituent, curcumin, on inflammatory disorders, pain, and their related patents. Phytotherapy Research. 2021;35(12):6489-6513.
- Shara M, Stohs SJ. Efficacy and safety of white willow bark (Salix alba) extracts. Phytotherapy Research. 2015;29(8):1112-1116.
- Vlachojannis J, Roufogalis BD, Chrubasik S. Systematic review on the safety of Harpagophytum preparations for osteoarthritic and low back pain. Phytotherapy Research. 2008;22(2):149-152.
- Vlachojannis JE, Cameron M, Chrubasik S. A systematic review on the effectiveness of willow bark for musculoskeletal pain. Phytotherapy Research. 2009;23(7):897-900.
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