“People with MS often ask if there is anything they can do to delay or avoid disability, and many people want to know if their diet can play a role, but there have been few studies investigating this,” said study author Kathryn C. Fitzgerald, ScD, of Johns Hopkins School of Medicine in Baltimore, Md., and a member of the American Academy of Neurology.

“While this study does not determine whether a healthy lifestyle reduces MS symptoms or whether having severe symptoms makes it harder for people to engage in a healthy lifestyle, it provides evidence for the link between the two.”

Tracking diets

The study, published in the journal Neurology involved 6,989 people with all types of MS who completed questionnaires about their diet as part of the North American Research Committee (NARCOMS) registry.

The definition of a healthy diet focused on eating more fruits, vegetables, legumes and whole grains and less sugar from desserts and sweetened beverages and less red meat and processed meat. The participants were divided into five groups based on how healthy their diet was.

Researchers also assessed whether participants had an overall healthy lifestyle, which was defined as having a healthy weight, getting regular physical activity, eating a better than average diet and not smoking.

The participants were also asked whether they had a relapse of MS symptoms or a gradual worsening of symptoms in the past six months and reported their level of disability and how severe their symptoms were in areas such as fatigue, mobility, pain and depression.

Better physical and mental health

People in the group with the healthiest diet were 20% less likely to have more severe physical disability than people in the group with the least healthy diet. The results were true even after researchers adjusted for other factors that could affect disability, such as age and how long they had MS. Individuals with the healthiest diets also were also around 20% less likely to have more severe depression than individuals with the least healthy diet.

Those with the best diet ate an average of 1.7 servings of whole grains per day, compared to 0.3 servings per day for those with the least healthy diet. For fruits, vegetables, and legumes (not including French fries), the top group had 3.3 servings per day while the bottom group had 1.7 servings per day.

People with an overall healthy lifestyle were nearly 50% less likely to have depression, 30% less likely to have severe fatigue and more than 40% less likely to have pain than people who did not have a healthy lifestyle.

The study also looked at whether people followed a specific diet, including popular diets such as Paleo, weight-loss plans or diets that have been touted in self-help books and websites as beneficial for people with MS, such as the Wahls’ diet. The researchers found that overall, past or current use of these diets was associated with modestly reduced risk of increased disability.

Dietary supplements for joint health have traditionally been dominated by glucosamine and chondroitin, but with the rise in joint problems in an ageing population new remedies are always being sought.

A 2008 study published in the journal Phytotherpy Research​​ suggested that daily supplementation with Pycnogenol reduced overall knee osteoarthritis symptoms by 21%. But just how Pycnogenol worked was unknown.

Working through the joint

New data from a human trial, published in the journal Nutrients​​, shines a light on the way the natural remedy works to reduce inflammation and pain.

The German scientists recruited 33 people diagnosed with severe osteoarthritis who scheduled for knee replacement surgery (arthroplasty). The volunteers were supplemented with 200 mg per day of Pycnogenol or no supplements (control group) for three weeks leading up to their scheduled surgeries, and synovial fluid samples were collected during surgery to detect and measure the presence of polyphenols.

Results showed that the polyphenols found in Pycnogenol including taxifolin, ferulic acid and catechin were distributed throughout the synovial fluid. On the other hand, taxifolin and ferulic acid were not detected in control group serum samples.

A natural delivery system

Osteoarthritis is a degenerative condition that affects the joints. As it progresses the surfaces within the joints become damaged and as a result the joint doesn’t move as smoothly as it should. The damage triggers several of the body’s repair mechanisms one of which is that the synovium (the inner layer of the joint capsule which produces synovial fluid) may thicken and make extra fluid. This causes your joint to swell.

Synovial fluid’s primary job is to provide cushion and lubrication for joints. A joint’s synovial membrane produces substances called albumin and hyaluronic acid that give the synovial fluid its viscosity and slickness. In addition, synovial fluid delivers nutrients to  and removes waste from the cartilage. Pycnogenol’s ability to be absorbed into the synovial fluid means it is also a natural delivery system for its anti-inflammatory benefits.

“To the best of our knowledge, this is the first study investigating polyphenol concentrations in human synovial fluid samples of patients with osteoarthritis,” wrote the researchers.

In an analysis published in the National Institute for Health Research (NIHR) Journals Library, the researchers showed that there is significant evidence to demonstrate that acupuncture provides more than a placebo effect.

Working with a team of scientists from the US, the University of York researchers brought together the results of 29 high quality clinical trials focused on patients treated with acupuncture and/or standard medical care.

In the majority of these trials, patients with chronic pain treated with acupuncture and standard medical care were tested against those who were provided with standard medical care alone, such as anti-inflammatory drugs and physiotherapy. The trials involved approximately 18,000 patients diagnosed with chronic pain of the neck, lower back, head, and knee.

An additive effect

The results shows that the addition of acupuncture compared to standard medical care alone significantly reduced the number of headaches and migraine attacks and reduced the severity of neck and lower back pain. It also showed that acupuncture reduced the pain and disability of osteoarthritis, which led to patients being less reliant on anti-inflammatory tablets to control pain.

Professor Hugh MacPherson, Professor of Acupuncture Research in the University of York’s Department of Health Sciences, said: “There has been an increase in practitioners using acupuncture as an intervention. Approximately four million acupuncture treatments are provided a year in the UK, but the evidence to show how clinically effective this form of treatment is has been limited.”

“Our aim was to bring together data from high quality clinical trials and provide a robust evidence base that will help reduce this uncertainty and support commissioners and health professionals in making informed decisions backed up with research.”

The authors also concluded that acupuncture is cost effective, with the value for money being rated as less than the threshold of £20,000 cost per quality of life year – a metric for cost-effectiveness used by the UK’s National Institute for Health and Care Excellence (NICE).

Hope for depression

Significantly, the team  note that in a study of 755 patients with depression, compared to antidepressants, those receiving acupuncture or counselling fared better and the improvements were largely sustained for up to 12 months after treatment.

Professor MacPherson said: “The front-line treatment for depression in primary care usually involves antidepressants; however, they do not work well for more than half of patients.

“In the largest study of its kind, we have now provided a solid evidence base to show that not only can acupuncture and counselling bring patients out of an episode of depression, but it can keep the condition at bay for up to a year on average.”

The researchers believe that their analysis provides definitive evidence that when acupuncture is used to treat chronic pain, the reductions in pain are substantially more than those measured from sham (placebo) acupuncture, which involves inserting needles at the ‘wrong’ locations, or using non-inserted needles (fake needles) at the correct locations.

Sham acupuncture is only used in clinical trials for comparative purposes, to help assess the effectiveness of true acupuncture.

Professor MacPherson added: “Our new data provides a significant step forward in treating chronic pain and managing depression, because patients and health professionals can now make decisions on acupuncture with more confidence. Not only is it more cost effective, but it reduces pain levels and improves mood levels, which could reduce over reliance on drugs that can sometimes result in unwanted side effects.”

Based on real world data from four European countries and almost 10 million people using a full range of non-steroidal anti-inflammatory drugs (NSAIDs) including COX-2 inhibitors (a new generation of NSAID commonly prescribed for arthritis pain).

The landmark analysis in the British Medical Journal found that NSAIDs raise risk of hospital admission for heart failure and that the magnitude of risk varied between individual NSAIDs and according to the dose prescribed.

Although not the first study to show such an association it is certainly one of the largest.

9 common drugs implicated

The risk of admission for heart failure increased for seven traditional NSAIDs (diclofenac, ibuprofen, indomethacin, ketorolac, naproxen, nimesulide, and piroxicam) and two COX-2 inhibitors (etoricoxib and rofecoxib). The increased risk of hospital admission ranged from 16% for naproxen to 83% for ketorolac.

Overall, the researchers found current NSAID users (defined as individuals who had used NSAIDs within the past 14 days) were 19% more likely to be admitted to the hospital with heart failure than past users (individuals who had not used NSAIDs for at least 183 days).

A particular of concern was that commonly used NSAIDS such as ibuprofen, diclofenac, and naproxen were all associated with increased risk of heart failure and that use of high doses of ibuprofen and diclofenac doubled the odds, though the increased risk associated with use of high dose naproxen was slightly lower.

By contrast with other selective COX-2 inhibitors (eg, rofecoxib, etirocoxib), celecoxib were not associated with increased risk of heart failure. But celecoxib was used mostly in low doses, so the safety of higher doses of celecoxib remains unexplored.

The researchers say that the new data “offers further evidence that the most frequently used individual traditional NSAIDs and selective COX 2 inhibitors are associated with an increased risk of hospital admission for heart failure. Moreover, the risk seems to vary between drugs and according to the dose.”

Previous studies highlight problems

Several studies have previously shows links between NSAIDs and health problems.

Earlier this year an analysis in the European Heart Journal found that Cox-2 inhibitors also increased the risk of other health problems including ulcers and increased blood pressure.

A 2014 study in BMJ Open found a significant increase in irregular heartbeat (atrial fibrilliation) in older adults taking NSAIDs. Current use was associated with a 76% greater risk of atrial fibrillation than never use, after taking account of other risk factors, such as age, sex, and underlying cardiovascular problems. Similarly, recent use (with the preceding 30 days) of these drugs was linked to an 84% greater risk of atrial fibrillation.

Also in 2014 an analysis in the journal Rheumatology found that NSAID use (aspirin and ibuprofen) almost double the risk for deep vein thrombosis (DVT) and pulmonary embolism, two lethal conditions.

An accompanying editorial to the latest study says “NSAIDs were first introduced over a century ago and most of the commonly used NSAIDs were registered in an era with few requirements for safety documentation. Therefore, for most of these drugs, there is an alarming lack of randomised studies addressing their safety.”

That’s the conclusion of a review conducted by a group of scientists from the National Center for Complementary and Integrative Health (NCCIH) at the National Institutes of Health.

The global burden of chronic pain is projected to be large and growing. Millions of adults in America, and elsewhere, suffer from chronic pain – pain that persists for at least 12 weeks – that may not be fully relieved by medications.  Studies shows they often turn to complementary health approaches to help.

GPs in the dark about alternatives

Many GPs however don’t know enough about these methods to make useful recommendations about which therapy works for which type of pain. Research into these approaches does exist but many conventional healthcare providers don’t have easy access to this information.

The new review of 105 US-based randomised controlled trials form the past 50 years, gives primary care providers – who frequently see patients with chronic pain – tools to inform decision-making on how to help manage that pain.

“For many Americans who suffer from chronic pain, medications may not completely relieve pain and can produce unwanted side effects.” said Richard L. Nahin, Ph.D., NCCIH’s lead epidemiologist and lead author of the analysis.

“Our goal for this study was to provide relevant, high-quality information for primary care providers and for patients who suffer from chronic pain.”

What works?

The review focused on seven approaches used for one or more of five painful conditions – back pain, osteoarthritis, neck pain, fibromyalgia, and severe headaches and migraine. A treatment was considered effective if it led to improvements in pain severity and pain-related disability and/or function that were statistically significant, when compared with a control group.

The researchers found promise in the following for safety and effectiveness in treating pain:

• Acupuncture and yoga for back pain
• Acupuncture and tai chi for osteoarthritis of the knee
• Massage therapy for neck pain with adequate doses and for short-term benefit
• Relaxation techniques for severe headaches and migraine.

Though the evidence was weaker, the researchers also found that massage therapy, spinal manipulation, and osteopathic manipulation may provide some help for back pain, and relaxation approaches and tai chi might help people with fibromyalgia.

None of the clinical trials reported significant adverse effects due to the interventions.

“These data can equip providers and patients with the information they need to have informed conversations regarding non-drug approaches for treatment of specific pain conditions,” said David Shurtleff, Ph.D., deputy director of NCCIH.

While other forms of exercise have been evaluated for their therapeutic potential in fibromyalgia, swimming hadn’t been evaluated with much scientific rigour. The results of this new trial showed swimming was as beneficial as walking, the positive effects of which have clearly been demonstrated.

The new study published in the Archives of Physical Medicine and Rehabilitation involved 75 sedentary women aged between 18 and 60 years who had fibromyalgia. They were divided randomly into two groups: 39 practiced freestyle swimming and 36 undertook moderate open-air walking. Both groups undertook their particular exercise three times a week for 12 weeks. The 50-minute sessions were overseen by physical education professionals specialising in rheumatology.

Over 12 weeks self-reported pain intensity fell by nearly half in both groups. There were also statistically significant – and similar – improvements in both groups for quality of life for instance in levels of social interaction and mental health. The physical health of women in both groups – as measured by aerobic capacity of the lungs and other measurements – also improved.

Hard to treat

Fibromyalgia is a condition that physicians find difficult to diagnose and treat – not the least because the condition does not have a specific test for diagnosis. It is about ten times more common in women than men (affecting around 5% of women), and it can be disabling.

The chronic non-inflammatory pain which fibromyalgia sufferers experience is due to a malfunctioning of the system that transmits and modulates the transmission of nervous stimuli between the body and the brain. This means that a normally painless prod or poke to a leg or arm may be felt as painful stimulus by someone with this condition.

In addition to magnified pain signals, the patient may experience spontaneous pain.” says lead researcher Jamil Natour, a professor of rheumatology at the Federal University of São Paulo (UNIFESP), “Diffuse tenderness with no anatomical explanation lasting for at least three months is a defining feature of this disease.”

Those suffering from the disease often also experience sleep disorders. Reduced levels of serotonin (a key neurotransmitter in mood regulation and pain sensitivity) are frequent, as well as alterations in the autonomic nervous system, which controls bodily functions such as heart rate, blood vessel contraction, sweating, salivary flow and intestinal movements. In addition, some 30% of people with fibromyalgia suffer from depression. Taken together, all these symptoms strongly affect the quality of fibromyalgia patients’ lives and make the disease a significant public health issue.

Exercise is key

Natour and his team have made several studies of exercise as a treatment for fibromyalgia. In an article published in 2003, Natour’s team showed that walking was better than stretching not only to reduce pain but also to improve depression and other emotional aspects of patients with fibromyalgia, in addition to enhancing cardiorespiratory fitness, as expected. Another study performed by the group in 2006 showed that deep-water running was also a good option for treatment of the disease.

“The results of this clinical trial showed swimming was as beneficial as walking, whose positive effects have clearly been demonstrated,” Natour concludes. “Physical exercise is an essential component of any treatment for fibromyalgia, and plenty of studies have demonstrated that low-impact aerobic exercise offers the most benefits. However, not everyone likes or is able to do the same kind of physical activity. Swimming can be a preferable option for a person who suffers from both fibromyalgia and knee arthrosis, for example.”

“We found that treatment using electroacupuncture provided small improvements in symptoms, disability, function, dexterity and pinch strength among patients with chronic mild to moderate symptoms of primary carpal tunnel syndrome when combined with nocturnal splinting,” write the researchers from Hong Kong.

Carpal tunnel syndrome (CTS) is a condition that causes a tingling sensation, numbness and sometimes pain in the hand and fingers. It is common during pregnancy and in those with diabetes and arthritis.

Usually, these uncomfortable sensations, which are  caused by compression of the media nerve which controls sensation and movement in the hands, develop gradually and can be worse during the night. They tend to affect the thumb, index finger and middle finger.

CTS affects about 3% of the general population and can limit daily activities in people, causing substantial work-related issues and resulting in disability claims. Night splinting and local steroid injection are two commonly recommended treatments for mild to moderate carpal tunnel syndrome.

The study published in CMAJ (Canadian Medical Association Journal), compared the use of electroacupuncture and night splinting to splinting alone in relieving mild to moderate pain from carpal tunnel syndrome over 17 weeks.

More relief

Patients were randomly assigned to the two groups, and of the 181 who started, 174 completed the study. They reported pain based on a symptom scale commonly used to assess pain from carpal tunnel syndrome.

Patients who received electroacupuncture combined with nighttime splinting reported better symptom relief at 5 and 17 weeks than the control group. The study also showed that splinting alone did not alleviate pain or improve function.

The researchers concluded that electroacupuncture combined with nocturnal splinting has the potential to provide some relief to patients with chronic mild to moderate discomfort from carpal tunnel syndrome.

Getting pain relief right in children is tricky because children are not just small adults. Their bodies are different, the doses required are not always easy to judge and because narcotics have many adverse effects in children including constipation, confusion and vomiting as well as respiratory distress.

The authors of this study from Iran, note that in Iranian culture aromatherapy with Damask rose (Rosa damascena), also known as Rose otto, essential oil is widely available and affordable and considered both safe and effective for children.

For those reasons, the authors chose to conduct a double-blind, placebo-controlled, clinical trial to evaluate the effect of aromatherapy with Damask rose on children’s postsurgical pain.

The 64 children in the study – aged 3-6 years old – were undergoing day, or outpatient surgery, and were randomised to receive either 1-2 drops of the rose essential oil or a placebo oil (sweet almond, Prunus dulcis) oil, which were placed on an eye pad and laid 30 cm from the child’s head. Another dose of oil was placed on the pads 3, 6, 9, and 12 hours after surgery. Thirty minutes after each aromatherapy dosing and the children’s subjective pain was measured after each application.

Both groups had routine postoperative care including sedation, antipyretics (to lower fever), and antibiotics.

While pain decreased in both groups over time, the Damask rose group had a significantly greater decrease in pain intensity compared with placebo after treatment at all time points which could not be accounted for by the conventional treatments.

What past research says

This small but encouraging study ads to what we know about aromatherapy and pain relief in children.

Historically not all studies show benefits, but several do including:

• A US study showing that the essence of sweat oranges reduced stress and relaxed the 5–14 year old children who were severely sick and underwent invasive procedures during hospitalisation.
• A UK study of HIV-positive children which found that a combination of lavender and chamomile helped the children sleep better and provided comfort and relief from pain -including reducing the children’s need for pain relief medications such as acetaminophen or morphine.
• Another US study in which inhalation of bergamot in children and adolescents undergoing stem cell transplantation showed that although aromatherapy alone did not reduce anxiety, nausea, and pain in children, it was effective as an addition to standard supportive treatments.

Larger studies would be welcome to understand which oils work best to help comfort distressed children and to give parents and healthcare professionals more resources to provide pain relief.

• For more on essential oils see our article Essential oils for health and wellbeing
• For more on rose essential oil see Rose oil – healing, uplifting and utterly romantic