Musculo-Skeletal Disorders - Osteoarthritis

By Kyle J. Norton

Musculoskeletal disorders (MSDs) is medical condition mostly caused by work related occupations and working environment, affecting patients' muscles, joints, tendons, ligaments and nerves and developing over time. A community sample of 73 females and 32 males aged 85 and over underwent a standardised examination at home. Musculoskeletal pain was reported by 57% of those interviewed. A major restriction of joint movement range was frequent in the shoulder but uncommon in other joints. A shoulder disorder was found in 27% of subjects, rheumatoid arthritis in 1% and osteoarthritis (OA) of the hand, hip, and knee in five, seven, and 18% of subjects, respectively. Disability was frequent: a walking distance of < 500 m was found in 60% and ADL dependency in 40% of the group. Factors related to one or both of these disability measures included female gender, hip and knee OA, impaired vision, cognitive impairment and neurological disease(1). Osteoarthritis I. Osteoarthritis (OA), a form of arthritis, is defined as a condition of as a result of aging causes of wear and tear on a joint, affecting over 25 million people in the United States in alone. II. Symptoms Symptoms of osteoarthritis is aching pain, stiffness, or difficulty moving the joint may develop in one or more joints. The pain usually gets worse in change of weather at night and in the advanced of the diseases the pain can occur even at rest. 1. Pain in joints of the hand Most commonly affected joints of the hand in osteoarthritis include the carpometacarpal joint of the thumb (CMC 1) and the distal (DIP) and proximal (PIP) interphalangeal joints. Ageing, female gender, genotype, heavy work causing pressure on the hands, and injuries predispose to osteoarthritis in the hand. The pain is likely to be due to secondary synovitis caused by molecules released from the joint cartilage(3). 2. Knee and Hip

Osteoarthritis (OA) of the knee and hip is among the most frequent and debilitating arthritic conditionsosteoarthritis. Key features of the pathological joint changes in OA include: cartilage destruction by proinflammatory cytokines, matrix metalloproteinases and prostaglandins, which promote a catabolic environment; subchondral bone remodelling and resorption; hypertrophic differentiation of chondrocytes; neovascularisation of synovial tissue; and focal calcification of joint cartilage(4). 3. Spine Vertebral deformity, in particular wedging, of the thoracic spine is not exclusively characteristic for osteoporosis and that certain vertebral deformities develop by mechanisms other than fracture. Osteoporotic fracture of the thoracic spine is characterized by an exaggerated reduction of the midheight to posterior height in addition to reduction of the anterior to posterior height. Osteoarthritis affecting the low back can lead to chronic low back pain (lumbago) and degenerative disc disease (spondylosis). Other researchers indicated that Postmenopausal women with lumbar spine disc degeneration are characterized by increased CII degradation. The contribution of lumbar spine disc space narrowing (DSN) to type II collagen (CII) degradation was similar to, and independent of, the contribution of radiologic knee OA or clinical hand OA. Lumbar spine disc degeneration in elderly patients should be assessed when analyzing levels of C-terminal crosslinking telopeptide of CII (CTX-II) in studies of knee, hip, and hand OA(5). III. Causes of Risk Factors A. Causes 1. Process of wear and repair Osteoarthritis (OA) is a widespread degenerative disease of skeletal joints and is often associated with senescence in vertebrates. OA commonly results from excessive or abnormal mechanical loading of weight-bearing joints ('wear-and-tear'), arising from heavy long-term use or specific injuries; yet, in the absence of injury, the aetiology of OA remains obscure(6) Improper repair process of injure of joints can result of symptoms of Osteoarthritis (OA) in old age, according to TCM. 2. Nutrient deficiency Poor nutritional conditions experienced by moose (Alces alces) early in life

are linked to greater prevalence of OA during senescence as well as reduced life expectancy(7). 3. Cartilage Cartilage is a flexible connective tissue which cushions the ends of bones in your joints and allows the joints to move smoothly. If the cartilage becomes rough or wears down due to aging or damage, it can causes pain as a result of bone in the joint rubbing against another bone. The above causes of Osteoarthritis (OA) are the result of injure, overuse, Rheumatoid Arthritis, etc. 4. Etc. B. Risk factors Aging changes in the musculoskeletal system contribute to the development of OA by making the joint more susceptible to the effects of other OA risk factors that include abnormal biomechanics, joint injury, genetics, and obesity. Age-related sarcopenia and increased bone turnover may also contribute to the development of OA(8). Other suggested that Osteoarthritis development in the injured joints is caused by intra-articular pathogenic processes initiated at the time of injury, combined with long-term changes in dynamic joint loading. Variation in outcome is reinforced by additional variables associated with the individual such as age, sex, genetics, obesity, muscle strength, activity, and reinjury(8a). 1. Age and age related sarcopenis Older adult are at increased risk of developing osteoarthritis as a result of muscular atrophy that occurs due aging. Normal aging in humans is associated with declines in skeletal muscle mass and strength and increased muscle fatigability (sarcopenia). These changes, together with the ageassociated decline in whole-body exercise tolerance (VO2max), can substantially reduce the amount and intensity of physical activities performed by elderly (>60 y) men and women (Evans 1995)(9). 2. Gender and race Women and Male Asian are at higher risk to develop osteoarthritis than men and male Caucasians, accordingly. The total prevalence of knee ROA was 24.3 % (CI 23.4-25.2 %). The whole prevalence in male patients was 24.3 % (CI 23.4-25.2 %); I2 = 59.4 (p = 0.002) and in female patients 32.6 % (CI 31.8-33.4 %); I2 = 49,1 (p < 0.001). Younger male patients (age 50-) had a prevalence of 5.6 (CI 4.5-6.8). In older patients (80+) the male prevalence

was 44.5 % (CI 39.6-49.5 %). In this age group female patients had a prevalence of 71.6 % (CI 67.6-75.3 %). The higher prevalence of knee ROA in female patients was significant (OR = 1.8 [1.7-1.9]; I2 = 46.0 [p < 0.001]). The prevalence of knee ROA was higher in male Asians compared with male Asians compared with male Caucasians(OR = 1.1, CI 0.9-1.2; p = 0.080) in tendency. This difference was significant in female patients (OR = 2.2; CI 2.0-2.4; p < 0.001). Furthermore another trend was evaluated. Female patients (70-79 years) from the birth-year cohort 1920- had a prevalence of 37.8 % (CI 35.9-39.7)%. In contrast female patients from the birth-year cohort 1920 had a prevalence of 62.8 % (CI 60.8-64.8 %) at 70-79 years. This difference was significant (OR = 2.8; CI 2.5-3.1; p < 0.001), according to research of Praxisklinik fr Unfallchirurgie und Orthopdie(10) 3. Deformation of bone People who were born with defective joints or cartilage are at increased risk of developing osteoarthritis. 4. Activity People who involve in activity such as sport are at higher risk to develop osteoarthritis. 5. Obesity Researchers at the McMaster University in the study of Obesity and knee osteoarthritis showed that the potential mechanisms to link obesity and knee osteoarthritis, as both a biomechanical and metabolic condition are strongly linked. It has been established that weight loss for obese patients with knee osteoarthritis is clinically beneficial, for pain reduction, and for improved function. The exact mechanism linking obesity and osteoarthritis is complex; however, it is our opinion that further evidence supporting the link between the two diseases will be useful in providing clinicians and researchers with targets for physical therapy and pharmacological management of obese patients with knee osteoarthritis(11). 6. Occupations Certain occupation are associated to the increased risk of osteoarthritis, especially to workers involving repetitive movements that stress on a particular joint. OA is potentially aetiologically linked to occupation in a sizeable segment of the population and that OA can no longer be considered an inevitable disease of ageing(12).

7. Genetics Genetic studies have identified polymorphisms associated with osteoarthritis and related end-points. These include genes in signaling cascades involved in joint and bone biology, as well as genes in inflammatory pathways and a cluster of five genes in perfect linkage disequilibrium in the 7q22 region(13). 8. Deficiency in DNA repair In the study of Analysis of osteoarthritis in a mouse model of the progeroid human DNA repair syndrome trichothiodystrophy, suggested that in premature aging TTD mice age-related changes in cartilage were not more severe compared to WT mice, in striking contrast with bone and many other tissues. This segmental aging character may be explained by a difference in vasculature and thereby oxygen load in cartilage and bone(14). 9. Other diseases and conditions may have a higher risk of developing the condition. a. Gout Gout is defined as a type of arthritis as a result of uric acid builds up in blood that leads to joint inflammation. Acute attacks of gout at individual joint sites are associated with the presence of clinically assessed OA. In a study of A total of 4249 completed questionnaires were returned (32%). From 359 attendees, 164 cases of gout were clinically confirmed. A highly significant association existed between the site of acute attacks of gout and the presence of OA (aOR 7.94; 95% CI 6.27, 10.05). Analysis at individual joint sites revealed a significant association at the first metatarsophalangeal joint (aOR 2.06; 95% CI 1.28, 3.30), mid-foot (aOR 2.85; 95% CI 1.34, 6.03), knee (aOR 3.07; 95% CI 1.05, 8.96) and distal interphalangeal joints (aOR 12.67; 95% CI 1.46, 109.91)(15) b. Rheumatoid arthritis Rheumatoid arthritis (RA) is defined as a chronic, systemic inflammatory disease that leads to the attack of flexible (synovial) joints, inflammation of the surrounding tissues and many tissues and organs. Rheumatoid arthritis (RA) cam cause progression of osteoarthritis in aging population. c. Paget's disease of the bone Paget's disease of bone is defined as a condition a chronic disorder that can lead to enlarged and misshapen bones resulting in excessive breakdown and formation of bone tissue causing pain, misshapen bones, fractures, and

arthritis in the joints near the affected bones(16). Paget's disease of bone (PDB) is a condition of unknown etiology characterized by excessive and abnormal bone remodeling. It may be localized to one or several skeletal segments. The disease seldom appears before the age of 40 years, but its prevalence tends to double each decade from the age of 50 onwards, reaching about 10% after ninth decade. PDB may virtually affect every bone in the skeleton. Affected bones are involved right away with no new involvement during the evolution. The basic symptom of the disease is bone pain, while complications depend on skeletal sites involved and range from secondary osteoarthritis to malignant degeneration(17). d. Septic arthritis Septic arthritis is a condition of inflammation of a joint as a result of bacterial or fungal infection of that it can lead to osteoarthritis. Others researchers suggest that joint sepsis should be considered if a patient with osteoarthritis develops new symptoms from a single joint with associated systemic features(18). e. Etc. 9. Etc. IV. Diseases associated with osteoarthritis Researchers suggested that OA is not simply a disease related to aging or mechanical stress of joints but rather a "metabolic disorder" in which various interrelated lipid, metabolic, and humoral mediators contribute to the initiation and progression of the disease process. Indeed, OA has been linked not only to obesity but also to other cardiovascular risk factors, namely, diabetes, dyslipidemia, hypertension, and insulin resistance(19a). Most people who suffer from osteoarthritis also suffer from one or more below comorbidities(19b) 1. Hypertension In the study of The economic burden associated with osteoarthritis, rheumatoid arthritis, and hypertension: a comparative study, Dr.Maetzel A, and scientists at the University Health Network Research Institute indicated thatThe economic burden incurred by RA significantly exceeds that related to OA and HBP, while differences between patients with a diagnosis of OA without HBP or a diagnosis of HBP alone were non-significant, largely owing to the influence of comorbidities(19).

2. Cardiovascular disease Researchers at the Erasmus University Medical Centre, in the study of Association of atherosclerosis with presence and progression of osteoarthritis: the Rotterdam Study, suggested that there is an associations of atherosclerosis with osteoarthritis of the knee and hand joints in women. The evidence was most solid for a relation with distal interphalangeal (DIP) osteoarthritis(20). 3. Peripheral vascular disease, The average vessel wall thickness of the popliteal artery was 1.09 mm in patients with generalized OA, and 0.96 mm in the matched normal reference population(21). 4. Congestive heart failure History of CHF was highly associated with risk for CHF hospitalization. Hypertension, diabetes, and older age also increased risk modestly. There appeared to be a dose-related increase in CHF with etoricoxib compared with diclofenac, which reached statistical significance when the etoricoxib 90 mg groups (osteoarthritis and rheumatoid arthritis) were pooled(22). 5. Renal function impairment In the study to investigate the urinary excretion of the collagen crosslinking compounds pyridinoline and deoxypyridinoline in patients with morphologically different subgroups of OA and RA, found that there was no significant difference in pyridinoline or deoxypyridinoline excretion when patients with four grades of severity of OA were compared, although the median excretion of pyridinoline and deoxypyridinoline for the OA group as a whole was raised above values found in a healthy control population(23). 6. Diabetes Several epidemiological and experimental data support the hypothesis that diabetes could be an independent risk factor for osteoarthritis (OA), at least in some patients, leading to the concept of a diabetes-induced OA phenotype. If confirmed, this new paradigm will have a dramatic impact on prevention of OA initiation and progression(24)

7. Respiratory disease People with Respiratory disease is also at a higher risk to develop osteoarthritis (OA). There are report that a 62-year-old woman was admitted because of chronic cough and bilateral infiltrates on chest roentgenogram. Additional history revealed that the patient had been taken diclofenac emulgel during the previous 10 years for arthrosis(25). 8. Etc. V. Diagnosis The aim of the diagnosis is to differentiate the diseases against other types of arthritis to avoid misdiagnosis and to rule out the other (secondary osteoarthritis)causes of osteoarthritis (OA). After taking the complex physical examination and careful exam the physical symptoms such as, Joint swelling, Joint tenderness, Decreased range of motion in joints, Visible joint damage, etc. some of the below tests may be necessary 1. Blood Test Although blood test is not necessary in many cases of osteoarthritis (OA), it can be helpful to rule other causes of the disease. 2. Synovial fluid analysis Synovial fluid analysis is the test to exam the joint synovial fluid. Abnormal joint fluid may look cloudy or abnormally thick may be a indication of inflammation or osteoarthritis. 3. X-rays X rays beside is one of the common used to diagnosed for findings of osteoarthritis (OA) such as abnormal joints, bone, joint space between adjacent bone, loss of joint cartilage, etc., it also can help to rule out other causes of pain and assist the decision-making as to when surgical intervention is found to be necessary. 4. MRI (magnetic resonance imaging) While MRI (magnetic resonance imaging) is a more sensitive imaging method, it is used less often than x-rays due to cost and availability. MRI scans show cartilage, bone, and ligaments.

5. Etc. VI. Preventions A. The Do and do not's list 1. Prevention recurrent injure to damage menisci The menisci are internal structures that are of central importance for a healthy knee joint; they have a key role in the structural progression of knee osteoarthritis (OA), and the risk of the disease dramatically increases if they are damaged by injury or degenerative processes. Meniscus damage might be considered a signifying feature of incipient OA in middle-aged and elderly people(26). 2. Take precaution if your occupation is at increased risk of osteoarthritis Osteoarthritis (OA) is one of the most important diseases as it frequently affects the active age group of the population and is the source of considerable loss of working hours and of disability. Compressive, torsional, pulling and angular movements common in certain occupations or sports may result in injuries of soft tissue, thus increasing the development of OA. Consequently, the main task is prevention at the place of work or in sporting activities(27). 3. Muscle strengthening and aerobic exercises Muscle strengthening and aerobic exercises are effective in reducing pain and improving physical function in patients with mild to moderate OA of the knee(28). 4. Maintain a healthy weight In the study to compare MRI-based knee cartilage T2 measurements and focal knee lesions and 36 month changes in these parameters, among knees of normal controls and knees of normal-weight, overweight, and obese subjects with risk factors for knee osteoarthritis (OA), indicated that increased BMI is associated with more severe cartilage degeneration as assessed by both morphological and quantitative MRI measurements(29). 5. Avoid dehydration Dr. Xu J, and the research team at the University of Michigan, in the study of Solid-state NMR spectroscopy provides atomic-level insights into the

dehydration of cartilage, showed that the dehydration reduced the mobility of collagen amino acid residues and carbon sugar ring structures in glycosaminoglycans but had no effect on the trans-Xaa-Pro conformation. Equally interestingly, our results demonstrate that the dehydration effects are reversible, and the molecular structure and mobility are restored upon rehydration(30). 6. Avoid intake of inflammatory foods Loading up on junk foods and fast foods contains high amount of trans fat of that increases the risk of inflammation causes of osteoarthritis (OA). Red meat, eggs, and wheat products all contain high amount of arachidonic acid, too much arachidonic acid in the diet will make your inflammation worse, etc. 7. Eat your fruits and vegetables Fruits and vegetables contains high amount of nutrients and antioxidant. Researchers found that rheumatoid joint fluid contains significant amounts hydroxyl radical. Its presence suggests a failure of the normal immune defense system within the joint as transferrin has no longer performed its normal function in chemicals binding, leading to inflammation. Other study suggested that once the inflammatory condition is progressing, free radicals and the chain of free radicals reaction cause radicals occur in high numbers in the affected area, elevating the swelling and promoting degeneration as it becomes a cycle process(31). 8. Replace regular beverage with green tea IL-1 is a major cytokine driving the inflammatory processes leading to the pathophysiology of osteoarthritis and other inflammatory diseases. epigallocatechin-3-gallate, a green tea polyphenol, was found to be effective in reducing IL-1-induced inflammatory cytokines, TNF, IL-6, granulocyte-macrophage colony-stimulating factor and several chemokines from human chondrocytes. The use of green tea polyphenols may be beneficial as a therapeutic addition to biologics that control IL-1 activity by increasing effectiveness and/or reducing dosage(32). 9. Etc.

B. Diet to prevent osteoarthritis The aims of the diet is to provide protection to avoid elevation of the swelling and promoting degeneration as it becomes a cycle process or aging causes of osteoarthritis 1. Green tea In the review of Green tea's active ingredient, epigallocatechin 3-gallate (EGCG), dr. Ahmed S. at the College of Pharmacy summarized that the limitations of the dose, pharmacokinetics, and bioavailability of EGCG in experimental animals and findings related to the EGCG-drug interaction. Although these findings provide scientific evidence of the anti-rheumatic activity of EGCG, further preclinical studies are warranted before phase clinical trials could be initiated with confidence for patients with joint diseases(33). 2. Salmon is the common name for Salmonidae. They are anadromous, born in fresh water, migrate to the ocean, then travel thousands of miles in the deep sea cold water throughout their life cycle and within to five years returning to the exacted location where they were born to reproduce and die. a. Weight loss In the investigation of supplementation with n3 long-chain polyunsaturated fatty acids (n3-LCPUFA) and its effect in body weight, found that At the end of the 1-month period, 16 children lost weight and 27 children gained weight. Multiple analysis demonstrated that supplementation with n3LCPUFA decreased HOMA-IR by 15% after adjusting for puberty, treatment adherence, changes in adipokines, and weight loss. Interaction between supplementation and weight loss was significant (p = 0.007), according to "Supplementation of n3 Long-chain Polyunsaturated Fatty Acid Synergistically Decreases Insulin Resistance with Weight Loss of Obese Prepubertal and Pubertal Children" by Lpez-Alarcn M, Martnez-Coronado A, Velarde-Castro O, Rendn-Macas E, Fernndez J. (34) b. Antioxidants In the research of the antioxidant effect of vitamin E after ingestion of salmon found that that megadoses of vitamin E, far from having prooxidative activity, actually increase the anti-oxidative capacity of the liver, especially after ingestion of salmon oil, according to "Effects of megadoses of dietary vitamin E on the antioxidant status of rats fed lard or salmon oil" by Flader D, Brandsch C, Hirche F, Eder K.(35)

c. Omega 3 fatty acids Omega 3 fatty acids is necessary to maintain the ratio of good and bad cholesterol, thus reducing the risk of cholesterol inflammation according to the study of "In vitro fatty acid enrichment of macrophages alters inflammatory response and net cholesterol accumulation" by Wang S, Wu D, Lamon-Fava S, Matthan NR, Honda KL, Lichtenstein AH., posted in PubMed (36) and forming of free radical in the heart cells, leading to heart diseases. d. Anti inflammationIt is said the Omega 3 fatty acids beside reduced the risk of inflammatory effects on our joints and improved blood flow, by regulating the migration of inflammatory cells that cause inflammation, but also autoimmune diseases as a result of the elevation of IL-1 and the proinflammatory leukotriene LTB(4) produced by omega-6 fatty acids, according to the study of "Omega-3 fatty acids in inflammation and autoimmune diseases" by Simopoulos AP.,(37) 3. Walnut tree is one of the Genus plant belong to the family Juglandaceae about 30130 ft). It is cultivated for its nut and kernel and for commercial purpose all over the world. a. Antioxidant effects In the compaeison of Compared with other common plant foods, walnuts (Juglans regia) and theirs antioxidant effects found that walnut consumption did not significantly change the plasma antioxidant capacity of healthy, well-nourished older adults in this pilot study. However, improvements in linoleic acid and pyridoxal phosphate were observed with chronic consumption, while total plasma thiols were enhanced acutely. Future studies investigating the antioxidant effects of walnuts in humans are warranted, but should include either a larger sample size or a controlled feeding intervention, according to "Chronic and acute effects of walnuts on antioxidant capacity and nutritional status in humans: a randomized, cross-over pilot study" by McKay DL, Chen CY, Yeum KJ, Matthan NR, Lichtenstein AH, Blumberg JB.(38) b. Inflammation defense Manganese superoxide dismutase (MnSOD), an enzyme located in mitochondria, is the key enzyme that protects the energy-generating mitochondria from oxidative damage caused by free radicals, according to the study of `The role of manganese superoxide dismutase in inflammation defense`by Li C, Zhou HM.(39)

c. Diabetes risk deficiency (too little) and efficiency (too much) of some essential trace metals may play a role in the development of diabetes mellitus, including manganese, according to the study of `Copper, chromium, manganese, iron, nickel, and zinc levels in biological samples of diabetes mellitus patients`by Kazi TG, Afridi HI, Kazi N, Jamali MK, Arain MB, Jalbani N, Kandhro GA.(40) 4. Dulse is a red seaweed of genus Palmaria, belong to Family Palmariaceae that grows attached to rocks by a "holdfast" in the North Atlantic and Northwest Pacific. It is commonly used in Ireland and Atlantic Canada both as food and medicinally and is now shipped around the globe. Dulse is found in many health food stores or fish markets or can be ordered directly from local distributors. a. Health benefits In the assessment of nutritional and physiological properties of edible seaweeds is presented. Seaweeds are traditionally consumed in Asia as sea vegetables found that Seaweeds showed important functional activities, such as antioxidant, antimutagenic and anticoagulant effect, antitumor activity, and an important role in the modification of lipid metabolism in human body. In conclusion, seaweeds have a high nutritional value, therefore an increase in their consumption, would elevate the foods offer to population, according to "[Nutritional evaluation and physiological effects of edible seaweeds].[Article in Spanish]" by Jimnez-Escrig A, Goi Cambrodn I. (41) b. Antioxidant In assessment of polyphenol content of the dulse extract of two grades of dulse harvested from Canadian Maritime locations differing in UV radiation exposure (i.e. west versus east coasts of Grand Manan Island, New Brunswick) and their antiodant effects found that The 1-butanol soluble extract from Grade 1 dulse (reduced UV-exposure) exhibited lower reducing activity versus Grade 2 dulse (greater UV exposure) reflecting a lower requirement for endogenous antioxidant protection. Grade 1 and 2 dulse extracts both inhibited (p0.03) AAPH-induced lipid peroxidation, but had no effect on AMVN-induced lipid peroxidation, demonstrating the aqueous nature of the antioxidants involved, according to "Extracts from dulse (Palmaria palmata) are effective antioxidants and inhibitors of cell proliferation in vitro" by Yuan YV, Carrington MF, Walsh NA.(42)

c. Weigh loss As a rich source of fiber, dulse beside enhances the process of digestion, it also helps to make the stomach feeling fullness, thus reducing the risk of insulin cause of food craving, leading to weight loss, According to the study of Free-living, overweight and obese adults (N=204, body mass index 25 to 45) with baseline LDL cholesterol levels 130 to 200 mg/dL (3.4 to 5.2 mmol/L) were randomized; 144 were included in the main analysis of participants who completed the trial without significant protocol violations, conducted by Provident Clinical Research, Glen Ellyn,(43) 5. Lime (Lemon) Lime is a species of Citrus Aurantifolia, belongs to the family Rutaceae. It has around shape are with green to yellow in color and 36 cm in diameter and native to Southeast Asia. a. Antioxidant In the analyzing the dichloromethane, ethanol and water extracts prepared from celery [Apium graveolens L. (Umbelliferae)], Jerusalem artichoke [Helianthus tuberosus L. (Compositae)], spinach [Spinacia oleracea L. (Chenopodiaceae)], chard [Beta vulgaris L. var. cicla (Chenopodiaceae)], purslane [Portulaca oleracea L. (Portulacaceae)], ispit, or borage [Trachystemon orientale (L.) G. Don (Boraginaceae)], garden rocket [Eruca sativa Mill. (Brassicaceae)], red cabbage [Brassica oleracea L. var. capitata f. rubra DC. (Cruciferae)], lime flower [Tilia tomentosa Moench (Tiliaceae)], cinnamon [Cinnamomum cassia Presl. (Lauraceae)], and rosehip [Rosa canina L. (Rosaceae)], found that the dichloromethane, ethanol and water extracts of cinnamon showed the best antioxidant effect among the extracts of the tested plants. The ethanol extract of cinnamon exhibited 63.02% inhibition against acetylcholinesterase and 85.11% inhibition against butyrylcholinesterase (BChE) at 200 g/mL(44) b. Vitamin C Besides is essential in preventing the breaking off small vein cause of hardening of the vessel wall, vitamin C also improves the digestive system in maximum absorption of vital nutrients. Overdoses can cause diarrhea, It also plays an important role in enhancing immune system fighting against the forming of free radicals that cause muscle damage, according to the study of "Does antioxidant vitamin supplementation protect against muscle damage?" by McGinley C, Shafat A, Donnelly AE.(45)

c. Immune system Since it contains high amount of flavonoid, it helps to improve the immune system fighting against forming of free radical causes of tumor and cancer, according to the study of "Dietary intake of selected flavonols, flavones, and flavonoid-rich foods and risk of cancer in middle-aged and older women" by Wang L, Lee IM, Zhang SM, Blumberg JB, Buring JE, Sesso HD.(46) 6. Etc. C. Antioxidants to prevent osteoarthritis 1. Immune system and functioning Free Radicals play an important role in the function of the Immune System. The immune systen produce free radicals to kill foreign microbes, but the production of free radical sometime can be excessive, leading to formation of a large number of free radicals that stimulate the formation of more free radicals, leading to even more damage, until they are brought to stop. a. Vitamin A vitamin A plays an essential roles in enhancing a broad range of immune processes, including lymphocyte activation and proliferation, T-helper-cell differentiation, the production of specific antibody isotypes and regulation of the immune response. b. Vitamin C Researchers found that vitamin C raised the concentration in the blood of immunoglobulin A, M that promotes the ability of antibodies and phagocytic cells to clear pathogens. c. Vitamin E In aged mice study showed that Vitamin E beside increased both celldividing and IL-producing capacities of naive T cells it also enhances the immune functions in association with significant improvement in resistance to influenza infection. d. Zinc Zinc, as a antioxidant is essential mineral in ading immune system by enhancing the proper function of T cells which belong to a group of white blood cells known as lymphocytes, in fighting against damaging free

radicals. 2. Antioxidants and osteoarthritis a. Vitamin E and fish oil In genetically altered mice study, researcher found that diet included fish oil plus vitamin E significantly reduce the levels of inflammation by analyzing the pro and anti-inflammatory cytokines in the blood serum. b. Glucosamine Since glucosamine, a compound of the simple sugar glucose and the amino acid glutamine, is a precursor for glycosaminoglycans, and they are a major component of joint cartilage. Study found that supplemental glucosamine may help to prevent cartilage degeneration and treat arthritis. c. DLPA (dl- phenylalanine) DLPA, a mixture of D-Phenylalanine and L-Phenylalanine, is a nutritional supplement amino acid. Researchers found that DLPA effectively reduces arthritis pain and joint inflammation in many patients. d. Glucosamine and Methylsulfonylmethane In a double-blind, placebo-controlled study with osteoarthritis of the knee were given a combination of glucosamine and MSM, or placebo. After 12 weeks, the results suggested combination of MSM and glucosamine may improve arthritis symptoms as compared to placebo. 3. Etc. D. Phytochemicals to prevent osteoarthritis 1. Epigallocatechin, including catechins, is a phytochemical of Flavan-3ols, in the group of Flavonoids (polyphenols), found abundantly in green tea, St John wort, black Tea, carob flour, Fuji apples, etc. a. Inflammatory effects In the determination of the up-regulated expressions of IL-8 or PGE(2) in Streptococci or PAMP-stimulated HDPF were inhibited by catechins, (-)epicatechin gallate (ECG) and (-)-epigallocatechin gallate (EGCG). In TLR2 ligand-stimulated HDPF, found that catechins might be useful therapeutically as an anti-inflammatory modulator of dental pulpal inflammation, according to "Tea catechins reduce inflammatory reactions via mitogen-activated protein kinase pathways in toll-like receptor 2 ligand-stimulated dental pulp cells" by Hirao K, Yumoto H, Nakanishi T,

Mukai K, Takahashi K, Takegawa D, Matsuo T.(47) b. Antiviral activities In the observation of Catechin derivatives including (-)-epicatechin gallate (ECG), (-)-epigallocatechin gallate (EGCG), (-)-epigallocatechin (EGC) and green tea extract (GTE) and theirs inhibition of the activities of cloned human immunodeficiency virus type 1 reverse transcriptase (HIV-1 RT), duck hepatitis B virus replication complexes reverse transcriptase (DHBV RCs RT), herpes simplex virus 1 DNA polymerase (HSV-1 DNAP) and cow thymus DNA polymerase alpha (CT DNAP alpha, found that GCG exerts a mixed inhibition with respect to external template inducer poly (rA).oligo (dT) 12-18 and a noncompetitive inhibition with respect to substrate dTTP for HIV-1 RT. Bovine serum albumin significantly reduced the inhibitory effects of catechin analogues and GTE on HIV-1 RT. In tissue culture GTE inhibited the cytopathic effect of coxsackie B3 virus, but did not inhibit the cytopathic effects of HSV-1, HSV-2, influenza A or influenza B viruses, according to "[The inhibitory effects of catechin derivatives on the activities of human immunodeficiency virus reverse transcriptase and DNA polymerases].[Article in Chinese]" by Tao P.(48) c. Antioxidants In the evaluation of the effects of the main polyphenolic components extracted from green tea leaves, i.e. (-)-epicatechin (EC), (-)epigallocatechin (EGC), (-)-epicatechin gallate (ECG), (-)-epigallocatechin gallate (EGCG) and gallic acid (GA), against free radical initiated peroxidation of human low density lipoprotein (LDL), found that The antioxidative action of the green tea polyphenols includes trapping the initiating and/or propagating peroxyl radicals with the activity sequence EC>EGCG>ECG>EGC>GA for the AAPH initiated peroxidation, and reducing the alpha-tocopheroxyl radical to regenerate alpha-tocopherol with the activity sequence of ECG>EC>EGCG>EGC>GA and ECG>EGCG>GA>EC>EGC for the AAPH-initiated and BPphotosensitized peroxidations respectively, according to "Antioxidative effects of green tea polyphenols on free radical initiated and photosensitized peroxidation of human low density lipoprotein" by Liu Z, Ma LP, Zhou B, Yang L, Liu ZL.(49) 2. Catechin is phytochemical of Flavan-3-ols, in the group of Flavonoids (polyphenols), found abundantly in white tea, green tea, black tea, grapes, wine, apple juice, cocoa, lentils, etc.

a. Body-weight regulation Green tea has been proposed as a tool for obesity management as strategies for weight loss and weight maintenance, as researchers found that a green tea-caffeine mixture improves weight maintenance, through thermogenesis, fat oxidation, and sparing fat free mass. The sympathetic nervous system is involved in the regulation of lipolysis, and the sympathetic innervation of white adipose tissue may play an important role in the regulation of total body fat in general, according to "Green tea catechins, caffeine and bodyweight regulation" by Westerterp-Plantenga MS.(50) b. Antioxidant activity In the research on polyphenolic compounds (included catechins) in the berries of edible honeysuckle and their biological effects, including recommended utilization, are reviewed found that These berries seem to be prospective sources of health-supporting phytochemicals that exhibit beneficial anti-adherence and chemo-protective activities, thus they may provide protection against a number of chronic conditions, e.g., cancer, diabetes mellitus, tumour growth or cardiovascular and neurodegenerative diseases, according to "Phenolic profile of edible honeysuckle berries (genus lonicera) and their biological effects" by Jurikova T, Rop O, Mlcek J, Sochor J, Balla S, Szekeres L, Hegedusova A, Hubalek J, Adam V, Kizek R.(51) c. Anti-inflammatory effect In the preparation of the gel of Chinese medicine catechu, and to observe the release mechanism in vitro and anti-inflammatory activity in rats, found that the optimum condition of extraction from catechu was as follows, the concentration of ethanol, ratio of raw material to solvent, ultrasonic time, and extraction temperature were 50% , 1: 12, 35 min and 60 degrees C, respectively. The formulation of catechu gel was carbomer-9 400.5 g, glycerol 5.0 g, the extracts of catechu 50.0 mL, and triethanomine 0.5 mL The gel was semitransparent and stable. The drugs released quickly. The catechu gel reduced the paw edema considerably in dose-dependent manner compared to carrageenan-induced rat, according to "[Preparation and pharmacodynamics studies on anti-inflammatory effect of catechu gel]. [Article in Chinese]" by Zheng X, Zheng C.(52) 3. Theaflavin-3,3'-digallate, a theaflavin derivative, is phytochemicals of Flavan-3-ols, in the group of Flavonoids (polyphenols) found abundantly in black tea.

a. Antioxidant capacities In the comparison of TF derivatives (theaflavin (TF(1)), theaflavin-3-gallate (TF(2)A), theaflavin-3'-gallate (TF(2)B), and theaflavin-3,3'-digallate (TF(3))) in scavenging reactive oxygen species (ROS) in vitro, indicated that positive antioxidant capacities of TF(2)B on singlet oxygen, hydrogen peroxide, hydroxyl radical, and the hydroxyl radical-induced DNA damage in vitro were found, according to "Evaluation of the antioxidant effects of four main theaflavin derivatives through chemiluminescence and DNA damage analyses" by Wu YY, Li W, Xu Y, Jin EH, Tu YY.(53) b. Antimicrobial activities In the evaluation of the antimicrobial activities of seven green tea catechins and four black tea theaflavins, found that (-)-gallocatechin-3-gallate, (-)epigallocatechin-3-gallate, (-)-catechin-3-gallate, (-)-epicatechin-3-gallate, theaflavin-3, 3'-digallate, theaflavin-3'-gallate, and theaflavin-3-gallate showed antimicrobial activities at nanomolar levels; (ii) most compounds were more active than were medicinal antibiotics, such as tetracycline or vancomycin, at comparable concentrations; (iii) the bactericidal activities of the teas could be accounted for by the levels of catechins and theaflavins as determined by high-pressure liquid chromatography; (iv) freshly prepared tea infusions were more active than day-old teas; and (v) tea catechins without gallate side chains, gallic acid and the alkaloids caffeine and theobromine also present in teas, and herbal (chamomile and peppermint) teas that contain no flavonoids are all inactive, according to "Antimicrobial activities of tea catechins and theaflavins and tea extracts against Bacillus cereus" by Friedman M, Henika PR, Levin CE, Mandrell RE, Kozukue N.(54) c. anti inflammation found that a single topical application of equimolar of black tea constituents (TF, theaflavin-3-gallate, theaflavin-3'-gallate, and theaflavin-3,3'-digallate) strongly inhibited TPA-induced edema of mouse ears. Application of TFs mixture to mouse ears 20 min prior to each TPA application once a day for 4 days inhibited TPA-induced persistent inflammation, as well as TPAinduced increase in IL-1beta and IL-6 protein levels. TFs also inhibited arachidonic acid (AA) metabolism via both cyclooxygenase (COX) and lipoxygenase pathways, according to "Inhibitory effects of black tea theaflavin derivatives on 12-O-tetradecanoylphorbol-13-acetate-induced inflammation and arachidonic acid metabolism in mouse ears" by Huang MT, Liu Y, Ramji D, Lo CY, Ghai G, Dushenkov S, Ho CT.(55)

4. Myricetin is a flavonol, belong to the flavonoid in Flavonoids (polyphenols), found in many grapes, berries, fruits, vegetables, herbs, as well as other plants. It has been used as antioxidant to lower cholesterol, treat certain types of cancer, etc. a. Antioxidant and cytotoxic activity In the evaluation of extracted from plants containing phenolic compound, including flavonoid-galloyl glycoside [myricetin 3-O-(2',3'4'-tri-O-galloyl)-l-rhamnopyranoside] and theirs antioxidant and cytotoxic effect found that the methanol extract exhibited high antioxidant activity (SC(50)=3.94 g/ml), which is correlated with its phenolic content. The extract also showed cytotoxic activity against Hep G2 (IC(50) value 1.41 g/ml) confirming its anticancer activity against hepatocellular carcinoma, according to the study of "Antioxidant and cytotoxic activity of polyphenolic compounds isolated from the leaves of Leucenia leucocephala" by Haggag EG, Kamal AM, Abdelhady MI, El-Sayed MM, El-Wakil EA, Abd-El-Hamed SS.(56) b. Antitumour and anti-inflammatory activities In the observation of of flavonoids isolated from Byrsonima crass and its effect on mammary tumour cells LM2, found that almost all the samples showed inhibitory activity to the release of NO but not of TNF-alpha. Of all substances tested, flavonoids 2 (quercetin) and 6 (myricetin) may show promising activity in the treatment of murine breast cancer by immunomodulatory and antiproliferative activities, according to "Isolated flavonoids against mammary tumour cells LM2" by Carli CB, de Matos DC, Lopes FC, Maia DC, Dias MB, Sannomiya M, Rodrigues CM, Andreo MA, Vilegas W, Colombo LL, Carlos IZ.(57) 5. Cyanidin is an anthocyanins (flavonals), in the group of Flavonoids (polyphenols), found abundantly in red apple and pear, bilberry, blackberry, blueberry, cherry, cranberry, peach, plum, hawthorn, etc. a. Antioxidants In the verification of the chemical properties included composition of anthocyanins and other polyphenols, antioxidant activity and profiles of antioxidants by HPLC post-column derivatization or TLC of Polish cultivars of blue-berried honeysuckles (Lonicera caerulea L.), wild and bog bilberr, found that The antioxidant activity of different blue-berried honeysuckle cultivars was similar to that of wild growing bilberries (range from 170 to 417 mol TE/g dm in ABTS and from 93-166 mol TE/g dm in DPPH and

Folin-Ciocalteu tests). The major anthocyanin in the blue-berried honeysuckle was cyanidin-3-glucoside that constituted 84-92% of the total anthocyanins. The TLC and HPLC post-column antioxidant profiles indicated that anthocyanins are the major antioxidants in all berries studied, according to "Phenolic Composition and Antioxidant Properties of Polish Blue-Berried Honeysuckle Genotypes by HPLC-DAD-MS, HPLC PostColumn Derivatization with ABTS or FC, and TLC with DPPH Visualization" by Kusznierewicz B, Piekarska A, Mrugalska B, Konieczka P, Namiesnik J, Bartoszek A (58) b. Anti-inflammatory Effects In the investigation of the cartilage-protecting and anti-inflammatory effects of a polyphenolic-enriched red raspberry extract (RRE; standardized to total polyphenol, anthocyanin, and ellagitannin contents), found that On treatment with RRE (50 g/mL), there was a decrease in the rate of degradation of both proteoglycan and type II collagen. In the in vivo antigen-induced arthritis rat model, animals were gavaged daily with RRE (at doses of 30 and 120 mg/kg, respectively) for 30 days after adjuvant injection (750 g of Mycobacterium tuberculosis suspension in squalene). At the higher dose, animals treated with RRE had a lower incidence and severity of arthritis compared to control animals, according to "Anti-inflammatory Effects of Polyphenolic-Enriched Red Raspberry Extract in an Antigen-Induced Arthritis Rat Model" by Jean-Gilles D, Li L, Ma H, Yuan T, Chichester CO, Seeram NP.(59) c. Obesity In the demonstration of Cyanidin-3-O--glucoside (Cy-3-g)-rich foods have been reported to inhibit the onset of obesity, found that Cy-3-g improves obesity and triglyceride metabolism in KK-Ay mice. The underlying mechanism is found to be partly related to the activation of LPL in plasma and skeletal muscle, and inhibition of LPL in adipose tissue following the activation of pAMPK, according to "Cyanidin-3-O--glucoside improves obesity and triglyceride metabolism in KK-Ay mice by regulating lipoprotein lipase activity" by Wei X, Wang D, Yang Y, Xia M, Li D, Li G, Zhu Y, Xiao Y, Ling W.(60) 6. Etc. V. Treatments A. In conventional medicine perspective

A.1. Medication The aim of the treatment is to relieve symptoms of the diseases 1. Acetaminophen a. Acetaminophen such as Tylenol can help to relive the pain of Osteoarthritis. In the study to compare the efficacy of tramadol 37.5 mg/acetaminophen 325 mg combination tablets (tramadol/APAP) with that of nonsteroidal anti-inflammatory drugs (NSAIDs) as maintenance therapy following tramadol/APAP and NSAID combination therapy in knee osteoarthritis (OA) pain, showed that overall adverse event rates were similar in both groups. Tramadol/APAP add-on significantly improved knee OA pain which had been inadequately controlled by NSAIDs. In those subjects who showed favorable response to tramadol/APAP and NSAID combination therapy, both tramadol/APAP and NSAIDs were effective at maintaining the pain-reduced state and there was no significant difference in efficacy between tramadol/APAP and NSAIDs(61). b. Side effects if overdose are not limit to b.1. Nausea and vomiting b.2. Appetite loss b.3. Sweating b.4. Diarrhea b.5. Irritability b.6. Abdominal pain b.7. Etc. 2. Nonsteroidal anti-inflammatory drugs (NSAIDs). a. In the observation to investigate the cost effectiveness of cyclooxygenase-2 (COX 2) selective inhibitors and traditional non-steroidal anti-inflammatory drugs (NSAIDs), and the addition of proton pump inhibitors to these treatments, for people with osteoarthritis, indicated that Prescribing a proton pump inhibitor for people with osteoarthritis who are taking a traditional NSAID or COX 2 selective inhibitor is cost effective. The cost effectiveness analysis was sensitive to adverse event data and the specific choice of COX 2 selective inhibitor or NSAID agent should, therefore, take into account individual cardiovascular and gastrointestinal risks(62). b. Side effects are not limit to Dr. Bjarnason I, and the research team at King's College School of Medicine and Dentistry, in the study of Side effects of nonsteroidal anti-inflammatory

drugs on the small and large intestine in humans, showed that Ingested NSAIDs may cause a nonspecific colitis (in particular, fenemates), and many patients with collagenous colitis are taking NSAIDs. Large intestinal ulcers, bleeding, and perforation are occasionally due to NSAIDs. NSAIDs may cause relapse of classic inflammatory bowel disease and contribute to serious complications of diverticular disease (fistula and perforation). NSAIDs may occasionally cause small intestinal perforation, ulcers, and strictures requiring surgery. NSAIDs, however, frequently cause small intestinal inflammation, and the associated complications of blood loss and protein loss may lead to difficult management problems. The pathogenesis of NSAID enteropathy is a multistage process involving specific biochemical and subcellular organelle damage followed by a relatively nonspecific tissue reaction. The various possible treatments of NSAID-induced enteropathy (sulphasalazine, misoprostol, metronidazole) have yet to undergo rigorous trials(63). 3. Narcotics Narcotics are natural opioid drugs derived from the Asian poppy may provide relief from more severe osteoarthritis pain., but with additive effect b.Side effects are not limit to b.1. Risk of dependence b.2. Dizziness and drowsiness b.3. Nausea and vomiting b.4. Headache and fatigue b.5. Etc. 4. Etc. A.2.. Non medication therapy Non medication therapy depending to the individual needs, including Patient education and self-management programs, weight loss if patient is overweight, physical therapy such as muscle strengthening, aerobic conditioning and tai chi exercise, occupational therapy for joint protection, etc. 1. In the study of What are the effects of strength training alone, exercise therapy alone, and exercise with additional passive manual mobilisation on pain and function in people with knee osteoarthritis compared to control?

What are the effects of these interventions relative to each other? showed that Exercise therapy plus manual mobilisation showed a moderate effect size on pain compared to the small effect sizes for strength training or exercise therapy alone. To achieve better pain relief in patients with knee osteoarthritis physiotherapists or manual therapists might consider adding manual mobilisation to optimise supervised active exercise programs(64) 2. In the study to determine if manual therapy improves pain and/or physical function in people with hip or knee OA.other suggested that manual therapy is more effective than exercise for those with hip OA in the short and long-term. Due to the small number of RCTs and patients, this evidence could be considered to be inconclusive regarding the benefit of manual therapy on pain and function for knee or hip OA(65). A.3. Surgery 1. Arthrocentesis plus corticosteroid Arthrocentesis is a medical procedure to remove joint fluid with a sterile needle to remove joint fluid for analysis and then injection of corticosteroids into the joints to relieve pain, swelling, and inflammation. The number of cortisone shots is limit every year as overdoses the medication can cause joint damage. 2. Arthroscopy Arthroscopy is a minimally invasive surgical procedure to examine the abnormalities of and damage to the cartilage and ligaments through the arthroscope and treat the disease. it is said that patients can recover from the arthroscopic surgery much more quickly than from open joint surgery. 3. Lubrication injections Injections of hyaluronic acid derivatives (Hyalgan, Synvisc) are recommended only to patients who have not found adequate pain relief from more conservative treatment options by offering pain relief. 4. Realigning bones Osteotomy is a surgical procedure used to Realigning bones and cartilage and reposition the joint to reduce knee pain by shifting your body weight away from the worn-out part of your knee. 5. Joint replacement Joint replacement is a surgical procedure of orthopedic surgery to remove

the damaged joint surfaces and replaces them with plastic and metal devices called prostheses. Joint replacement is considered as a treatment only for patient with severe joint pain or dysfunction that can not be alleviated by other less invasive treatments. 6. Etc.

B. In herbal medicine perspective 1. Stinging nettle In the study of Stinging nettle cream for osteoarthritis by Keith Rayburn, MD; Eric Fleischbein, PharmD; Jessica Song, PharmD; Blaine Allen, RN; Mary Kundert, PharmD; Charles Leiter, PharmD; Thomas Bush, MD, showed that Stinging nettle could prove beneficial to patients with osteoarthritis in 2 general ways: (1) pain relief and (2) disease process modification. The intact leaf hair's sting could provide a counterirritation that decreases pain by depleting substance P, similar to the effect of capsaicin(66). 2. Ginger In a report of a study to explicate the phenomenon of ginger compresses for people with osteoarthritis, showed that Seven themes were identified in the data: (1) Meditative-like stillness and relaxation of thoughts; (2) Constant penetrating warmth throughout the body; (3) Positive change in outlook; (4) Increased energy and interest in the world; (5) Deeply relaxed state that progressed to a gradual shift in pain and increased interest in others; (6) Increased suppleness within the body and (7) More comfortable, flexible joint mobility. The essential experience of ginger compresses exposed the unique qualities of heat, stimulation, anti-inflammation and analgesia(67). 3. Devil's claw Glucosamine, Harpagophytum procumbens(Devil's claw), and acupuncture are among the most commonly used complementary and alternative medicine approaches utilized by patients suffering from osteoarthritis(68). 4. Hot Chilli (Capsaicin) "Topical capsaicin is not associated with any severe systemic adverse effects. However, stinging and burning, particularly during the first week of therapy, is reported by many patients. Topical capsaicin merits consideration

as adjuvant therapy in conditions such as post-herpetic neuralgia, diabetic neuropathy and osteoarthritis, where the pain can be chronic and difficult to treat|", said Dr Rains C, and Bryson HM(69). 5. Etc. C. In traditional Chinese medicine perspective According to the article of Osteoporosis & Osteoarthritis in TCM Therapy by Chun Yi, Lu O.M.D., LAc.(70), Osteoarthritis is caused by blood stagnation and blood stasis. C. 1. Shu Jing Huo Xue Tang (Clematis and Stephania Combination) used to activate the blood and dispels blood stasis, induce downward movement of the blood, and strengthen the tendons and bones, reduce pain and inflammation and swollen of the joint lining and improve joint function. Depending to the patients situations, the following modifications are recommended 1. For pain in the arm or upper body, add Gui Zhi (Cinnamomum cassia). 2. For foot pain or pain in the lower body, add Mu Gua (Chaenomeles speciosa) or Yi Yi Ren (SemenCoix). 3. For qi deficiency, add Ren Shen (Radix Ginseng) or Ci Wu Jia (Siberian Ginseng) C.2. Shen Tong Zhu Yu Tang (Cnidium and Chiang Huo Combination) 1. Shen Tong Zhu Yu Tang (Cnidium and Chiang Huo Combination) used to activate the blood, dispel blood stasis and wind-dampness, alleviate pain, unblock the meridians, promote the flow of qi, etc. 2. The ingredients of this formula included the following herbs: 2.1.ao Ren (Semen Prunus persica), 2.2. Hong Hua (Flos Carthamus tinctorius), 2.3.Wu Ling Zhi (Excrementum Trogopteri seu Pteromi), 2.4. Niu Xi (Radix Achyranthes bidentata) and 2.5. Dang Gui (Radix Angelica sinensis) Depending to on the patients situations, the following modifications are recommended: a. For slight fever, add Cang Zhu (Atractylodes lancea) or Hunag Bo (Cortex Phellodendron amurense). b. For Weakness, add Huang Qi (Radix astragalus). C.3. Yi Yi Ren Tang (Coix Combination) 1. The formula is affliction of wind-cold-dampness marked by painful joints

and accompanied by numbness also difficulty in stretching and swelling in the joints. it typically works in about eight weeks, and reduces pain at least 50 %, but often leaves patients pain free. 2. Ingredients of the fomula include 2.1 Ma Huang (Herba Ephedra sinica), 2.2. Yi Yi Ren (Semen Coix lacryma-jobi), 2.3. Gui Zhi (Ramulus Cinnarmomum Cassia), 2.4. Cang Zhu (Rhizoma Atractylodes lance), 2.5. Dang Gui (Radix Angelica sinensis), 2.6. Shao Yao (Radix Paeonia lactiflora) and 2.7. Zhi Gan Cao (Radix Glycyrrhiza uralaensis preparata) Depending to the patients situations, the following modifications are recommended: a. For upper joints pain, add Ge Gen (Radix Puerariae lonatae) b. For lower joints pain, add Chuan Niu Xi (Radix Cyathulae) c. For serious whole joints pain, add Yan Hu Suo (Rhizome Corydalis) If you want to read the complete article, please follow the link of (70) Super Immunity Learning To Improve The Function Of Your Immune System The Most Powerful Thing You Can Do To Improve Your Health And Energy Level. For the series of Most common Diseases of Ages of 50+ please visit http://medicaladvisorjournals.blogspot.ca/p/better-of-living-health-50over.html For general health, please visit http://medicaladvisorjournals.blogspot.ca/p/general-health.html References (1) http://www.ncbi.nlm.nih.gov/pubmed/7864688 (2) http://health.yahoo.net/channel/musculoskeletal-disorders.html (3) http://www.ncbi.nlm.nih.gov/pubmed/22448556 (4) http://www.ncbi.nlm.nih.gov/pubmed/22471357 (5) http://www.ncbi.nlm.nih.gov/pubmed/15476251 (6) http://www.ncbi.nlm.nih.gov/pubmed/20618843 (7) http://www.ncbi.nlm.nih.gov/pubmed/20618843

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