A Complementary Approach to Pain Management

Meenakshi Khatta, MS, CRNP


Topics in Advanced Practice Nursing eJournal. 2007;7(1) 

In This Article

Herbal Preparations

Herbal medicines are among the most popular forms of complementary treatments. In the United States, the annual expenditure on herbal remedies exceeds 1.5 billion dollars and grows each year by approximately 25%.[36] Between 1990 and 1997, the use of herbal remedies in the United States increased by 380%.[37] A large proportion of these herbal remedies is used for musculoskeletal pain.[38] Patients' reasons for trying herbal medicines are complex. Prominent motivators are the wish to leave no option untried and the desire to benefit without incurring the risk of adverse effects.

Most of the herbal medicines have an effect on the eicosanoid metabolism, inhibiting one or both of the cyclo-oxygenase and lipoxygenase pathways. The ingredients of phytomedicines may be synergistic or antagonistic. Ideal extract doses and treatment periods still have to be determined. In most cases, herbal treatments are based on traditional use, which is a notoriously unreliable indicator of effectiveness.[39] The substances included in this report represent several of the most popular herbal analgesics for which there are some data in the literature.

Cayenne (Capsicum frutescens). In a placebo-controlled trial involving 45 fibromyalgia patients, capsaicin plasters were compared with placebo plasters. Capsaicin is the active ingredient of cayenne. Patients receiving the active therapy experienced less tenderness and significant increase in grip strength. There were no significant differences in pain scores.[40]

A recent Cochrane review outlined 3 low-quality trials using various topical preparations of Capsicum frutescens (cayenne) and found moderately favorable results compared with placebo.[41]

Devil's claw. In a double-blind RCT, devil's claw (Harpagophytum procumbens) taken for 3 weeks was compared with placebo in 50 subjects with osteoarthritis.[42] The herbal preparation was reported as significantly better than placebo for pain reduction. In another study, 89 patients with osteoarthritis were treated for 2 months with devil's claw or placebo. Again, the herb produced reduction in pain and increase in mobility.[43]

Phytodolor. The efficacy of Phytodolor (a proprietary preparation that contains Populus tremula, Fraxinus excelsior, and Solidago virgaurea [goldenrod]) for painful arthritic conditions has been demonstrated in a number of studies. In one study, 108 hospitalized patients with joint pain had greater pain relief from either Phytodolor or piroxicam (Feldene) over 4 weeks compared with placebo.[44] A systematic review of 10 RCTs with a total sample size of 1035 patients with RA was completed.[45] The results of this review showed positive results with this herb.

Willow bark (Salix alba). A systematic review of the literature revealed inconsistent results for proprietary willow bark extract for either osteoarthritis or chronic low back pain.[46]

A recent Cochrane review identified 2 moderate-quality trials using willow bark in combination with rescue medication for painful syndromes; both studies demonstrated short-term improvement in pain.[41]

Ayurvedic preparations. Boswellia (Boswellia serrata), an ayurvedic preparation, has demonstrated anti-inflammatory activity in vitro by reducing leukotriene synthesis.[47] One study comparing a 3600-mg extract with placebo in outpatients with active rheumatoid arthritis, however, did not show positive result.[48] Ayurvedic medicine is an ancient system of healing that originated in India over 4000 years ago. The modalities used include diet, natural therapies, and herbs, depending on body type, and place equal emphasis on body, mind, and spirit.

An ayurvedic herbal mixture of Withania somnifera (winter cherry or ashwagandha), Boswelia serrata, Zingiber officinale (ginger), and Curcurma longa (turmeric) has been tested in a double blind RCT with 182 patients suffering from chronic RA.[49] Participants were treated for 16 weeks. Of the multiple end points, only joint swelling showed a significant intergroup difference in favor of this preparation.

Gamma-linolenic acid (GLA)-containing herbs. Blackcurrant (Ribes nigrum) seeds contain high levels of GLA, an essential fatty acid that exerts anti-inflammatory activity by interfering with prostaglandin metabolism.[50] In an RCT comparing blackcurrant seed oil 15 capsules/day with placebo over 25 weeks, patients with RA showed objective signs of reduced disease activity, but overall clinical response, using 4 distinct measures, did not vary between groups.[51]

Two RCTs have shown positive results using borage (Boragio officinalis), another rich source of GLA, for painful conditions compared with placebo:

  1. A total of 37 RA patients suffering from active synovitis given 1.4 g/day of GLA in the form of borage seed oil showed clinical improvement on several measures compared with those who received cotton seed oil placebo[52]; and

  2. In 56 patients with active RA given GLA 2.8 g/day vs sunflower seed oil, the GLA group showed statistically significant and clinically relevant reduction in signs and symptoms of disease activity as well as at least 25% improvement in 4 measures, which was significantly better than the placebo group.[53]

Evening primrose (Oenothera biennis) oil capsules containing 540 mg of GLA were tested in a 3-arm RCT against 240 mg of eicosapentaenoic acid (EPA) plus 540 mg of GLA, or placebo in 49 RA patients.[54] The results showed subjective improvement in symptoms as well as a reduction in NSAID consumption in both experimental groups but no objective change in clinical measures.

Many consumers are led to believe that herbal medicines are "natural" and, therefore, safe. The truth is that all such treatments have been associated with numerous, diverse adverse effects. This is hardly surprising given that medicinal herbs contain pharmacologically active ingredients. The largely unregulated status of herbal medicines in most countries has been associated with suboptimal product quality that, in turn, may present serious safety issues.


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