Prescription Free
Quality of life can be significantly improved using a variety of strategies that don’t require a prescription. The role of the gut microbiome in pathology and health is now widely recognised, and can be improved with a quality diet and probiotics. Stress is well understood to increase inflammation, and practices such as meditation and being in nature can reduce its impact on health. Meditation can be learnt from a range of online and printed guides, or from professional psychological support. Given the serious impact that arthrofibrosis has on an individual’s quality of life, psychological support may be an important treatment option. Massage and exposure to non-burning sunlight are also powerful tools for reducing inflammation.
Good quality sleep is essential for healthy healing, and can be improved by good sleep hygiene and the use of melatonin where this is medically appropriate. People over the age of 50 should be accessed for sleep apnoea, since this condition is very common, and is frequently not diagnosed. People who snore are very likely to have sleep apnoea.
Several anti-inflammatory medications and supplements can help and don’t require a prescription. These include low-dose aspirin, omega 3 fatty acids, probiotics, and several supplements. While a large number of supplement manufacturers claim their products reduce inflammation there is little or no quality research to support most of these, and caution is needed since some have the potential to do harm. Please consult your doctor before starting a new over-the-counter medication or supplement, some can interact with medications, or be contraindicated for medical reasons. It’s also important not to take more than the recommended daily intake (RDI) of vitamins and minerals in supplements. Supplements that contain more than one ingredient frequently have in excess of the RDI. In addition to interactions with medications, supplements sometimes interact and interfere with each other, and long-term intake of some can lead to adverse effects. ConsumerLab has more information about these considerations.
Alternative Medicine
The IAA supports practices and treatments for arthrofibrosis that are supported by scientific evidence. At this time this does not include alternative medical practices such as chiropractic, osteopathy, acupuncture, homeopathy and crystal therapy.
Low Dose Aspirin
Aspirin reduces inflammation and stimulates the production of the body’s natural anti-inflammatory molecules, called resolvins [1]. The production of resolvins and related molecules is essential for healthy wound healing - inflammation cannot resolve if resolvins are not made. Aspirin also reduces pro-fibrotic factors and the progression of fibrosis [1] and is widely used to treat heart disease (heart fibrosis). People with sensitive stomachs may need to take encapsulated low doses.
References
Usher, K. M. et al. Pathological mechanisms and therapeutic outlooks for arthrofibrosis. Bone Research 7, doi:10.1038/s41413-019-0047-x (2019).
Low Dose Aspirin
Omega 3 Fatty Acids
Omega 3 fatty acids are essential for good health but are lacking in the typical western diet. These fatty acids are the building blocks of resolvins, the compounds the body makes to resolve inflammation [1]. A lack of omega 3s in the diet can be corrected by taking supplements. Compare the amounts of DHA and EPA, the important components of these supplements, on the side of the bottle to find the best value for money.
References
Usher, K. M. et al. Pathological mechanisms and therapeutic outlooks for arthrofibrosis. Bone Research 7, doi:10.1038/s41413-019-0047-x (2019).
Omega 3 Fatty Acids
Dietary approaches
An increase in dietary fibre and reduction in sugar and processed carbohydrates can be useful in reducing inflammation [1]. People with arthrofibrosis should consider cutting out sugary drinks and treats such as cake and biscuits because sugars directly promote inflammation. The microbes in the intestines play a large role in regulating inflammation and fibrosis [2] and a poor diet feeds pathogenic bacteria [3]. Plant antioxidants (polyphenols and isoflavanoids) have anti-inflammatory effects and are best consumed as food, rather than supplements. Plants contain mixed compounds that work together with each other and with fibre to enhance anti-inflammatory effects [3].
References
Dietary Approaches
Usher, K. M. et al. Pathological mechanisms and therapeutic outlooks for arthrofibrosis. Bone Research 7, doi:10.1038/s41413-019-0047-x (2019).
Loomba, R. et al. Gut Microbiome-Based Metagenomic Signature for Non-invasive Detection of Advanced Fibrosis in Human Nonalcoholic Fatty Liver Disease. Cell Metab 25, 1054-1062 e1055, doi:10.1016/j.cmet.2017.04.001 (2017).
Carding, S., Verbeke, K., Vipond, D. T., Corfe, B. M. & Owen, L. J. Dysbiosis of the gut microbiota in disease. Microb Ecol Health Dis 26, 26191, doi:10.3402/mehd.v26.26191 (2015).
Probiotics
A high quality probiotic taken with a diet high in fibre (fruit, vegetables, nuts, berries) can be effective in correcting gut microbiomes that are disrupted by too many pathogenic bacteria (dysbiosis). People who have had surgery or taken antibiotics may have dysbiosis, because many of the “good” beneficial bacteria are killed, and the wrong types take over. A predominance of the wrong type of bacteria in the intestines can promote fibrosis [2], inflammation and abnormal nerve signalling and adversely affect brain function via a range of mechanisms, including the molecules they produce [3]. Therefore, correcting a microbial imbalance may play an important role in healthy healing.
References
Probiotics
Usher, K. M. et al. Pathological mechanisms and therapeutic outlooks for arthrofibrosis. Bone Research 7, doi:10.1038/s41413-019-0047-x (2019).
Loomba, R. et al. Gut Microbiome-Based Metagenomic Signature for Non-invasive Detection of Advanced Fibrosis in Human Nonalcoholic Fatty Liver Disease. Cell Metab 25, 1054-1062 e1055, doi:10.1016/j.cmet.2017.04.001 (2017).
Carding, S., Verbeke, K., Vipond, D. T., Corfe, B. M. & Owen, L. J. Dysbiosis of the gut microbiota in disease. Microb Ecol Health Dis 26, 26191, doi:10.3402/mehd.v26.26191 (2015).
Massage
Deep tissue massage of the muscles of the affected limb can help to increase blood flow and lymph fluid movement, and decrease inflammation. Massage of the joint itself, particularly around the surgical site, should only be considered after the wound has healed well, and performed carefully so that bruising doesn’t occur. Massage tools include powered deep tissue devices such as the Hypervolt percussion gun and manual devices such as Graston tools [1]. In addition, inflatable pulsed compression devices such as Normatec systems can increase blood and lymph flow and may be particularly helpful during post-operative recovery.
References
Usher, K. M. et al. Pathological mechanisms and therapeutic outlooks for arthrofibrosis. Bone Research 7, doi:10.1038/s41413-019-0047-x (2019).
Massage
Supplements
A blood test to determine the levels of essential vitamins and minerals should be performed prior to surgery and afterwards if recovery is sub-optimal. Chronic inflammation is associated with deficiencies, including vitamin D, potassium and iron [1]. Deficiencies should be corrected using supplements or by diet. Unfortunately, the quality of supplements varies widely and is not regulated. ConsumerLab independently tests supplements for a range of toxic compounds and to identify products that contain the stated dose.
Plants contain a wide variety of anti-inflammatory polyphenols and isoflavanoids that promote good health, and eating a diet rich in plants is known to be beneficial. Several plant compounds are scientifically proven to reduce inflammation in their extracted form, including sulforaphane (Avmacol) and quercetin, and are used in cancer trials. However, supplements (other than essential vitamins that are lacking) should be used with caution since they can interact with medications, cause an allergic reaction, or interfere with an existing medical condition. Many are not bioavailable (not absorbed) and are therefore likely to be a waste of money. Others are potentially harmful since they contain substances in much higher doses or in a form that has undesirable side effects.
References
Usher, K. M. et al. Pathological mechanisms and therapeutic outlooks for arthrofibrosis. Bone Research 7, doi:10.1038/s41413-019-0047-x (2019).
Supplements
Avmacol
Avmacol is a convenient way to obtain sulforaphane and myrosinase
Sulforaphane is a compound found in cruciferous vegetables such as broccoli and cabbage. It has powerful health benefits and activates around 300 genes that are involved in anti-inflammatory pathways. It’s particularly useful as it inhibits inflammation at the same time as supressing oxidative stress (ROS), providing a novel drug target with potential across a range of conditions. Sulforaphane is one of the best-studied bioactive agents in cruciferous vegetables, with anti-fungal, anti-bacterial, anti-viral, anti-inflammatory and anti-oxidative effects [1]. Oxidative stress and chronic low grade inflammation all appear to play important roles in fibrosis [2] and oxidative stress (ROS) is highly efficient in activating latent TGF-β1, the key driver of fibrosis [3].
Sulforaphane reversed differentiation of lung fibroblasts into myofibroblasts in vitro via Nrf2 [4]. It decreased α-SMA in myofibroblasts and collagen 1 expression in vitro [4,5], and decreased cell proliferation, migration and contraction in vitro [5].
Broccoli sprouts
Unfortunately, there isn’t a lot of sulforaphane in the mature parts of the plants we normally eat, and cooking de-actives the enzyme myrosinase, which is required to convert sulforaphane into the biologically active form. So, it’s difficult to eat enough cruciferous vegetables every day to obtain a significant benefit.
Fresh 3 day-old broccoli sprouts contain high levels of sulforaphane and myrosinase, and are a good source of these compounds. There is quality research that shows eating 100 g of broccoli sprouts every day provides powerful anti-inflammatory effects. Unfortunately, shop bought sprouts are frequently contaminated, and it’s best to grow your own, and keep an eye out for contamination. See Dr Rhonda Patrick on how to grow broccoli sprouts, and the health benefits from consuming them [6].
Avmacol
Avmacol is a more convenient way to obtain sulforaphane and myrosinase compared to growing your own sprouts. It has been extensively tested by independent research laboratories, so, unlike other products, we can be confident that it has what it says it has on the label. Many other products on the market only have sulforaphane and because they lack active myrosinase only a very small amount of the sulforaphane is biologically active.
Avmacol is currently undergoing clinical trials for lung fibrosis and cancer, but hasn’t been tested for arthrofibrosis.
Some people are allergic to sulphur compounds, and should not take Avmacol. People on medications should check for drug interactions.
References
Avmacol
Lozanovski, V. J. et al. Broccoli sprout supplementation in patients with advanced pancreatic cancer is difficult despite positive effects-results from the POUDER pilot study. Invest New Drugs, doi:10.1007/s10637-019-00826-z (2019).
Vaziri, N. D. et al. Dose-dependent deleterious and salutary actions of the Nrf2 inducer dh404 in chronic kidney disease. Free Radic Biol Med86, 374-381, doi:10.1016/j.freeradbiomed.2015.04.022 (2015).
Ahamed, J. & Laurence, J. Role of Platelet-Derived Transforming Growth Factor-beta1 and Reactive Oxygen Species in Radiation-Induced Organ Fibrosis. Antioxid Redox Signal27, 977-988, doi:10.1089/ars.2017.7064 (2017).
Kyung, S. Y. et al. Sulforaphane attenuates pulmonary fibrosis by inhibiting the epithelial-mesenchymal transition. BMC Pharmacol Toxicol19, 13, doi:10.1186/s40360-018-0204-7 (2018).
Artaud-Macari, E. et al. Nuclear factor erythroid 2-related factor 2 nuclear translocation induces myofibroblastic dedifferentiation in idiopathic pulmonary fibrosis. Antioxid Redox Signal18, 66-79, doi:10.1089/ars.2011.4240 (2013).
https://www.foundmyfitness.com/episodes/how-to-grow-broccoli-sprouts
Sunlight
Health Benefits of Sunlight
People seem to have a powerful natural instinct to be in sunlight. Ask somebody where they would like to go for a holiday, and the chances are they’ll tell you they would like to go somewhere warm and sunny. We seem to know that being outdoors and in sunlight is good for us, but for many years we’ve been told to avoid the sun. It’s certainly true that being sunburnt is bad for you and increases the risk of melanoma. However, recent research has found what we all felt in our bones – that (non-burning) sunlight is good for us. Even our pets appear to know this, rushing outdoors to lie in the sun. An excellent paper that reviews these recent discoveries is “Melatonin and the Optics of the Human Body” [1].
This paper describes the way in which certain wavelengths of sunlight, known as Near Infra-red Radiation, or NIR, produces melatonin in the mitochondria (the power producers) in the majority of our cells, including the major organs, skin, brain, gastrointestinal tract, eyes, etc . Melatonin is a powerful anti-oxidant and when produced inside cells it effectively mops up the highly damaging reactive oxygen species (ROS) that are produced by mitochondria as a normal part of living (breathing oxygen). So, NIR-induced melatonin prevents ROS from causing cell damage, inflammation, and cell death. Although more research is needed, it seems likely that without exposure to NIR our bodies will have a lot more inflammation.
This knowledge is starting to be utilised for therapy, with NIR phototherapy treatments for wound healing, dementia, eye disease and PTSD, and lamps can be purchased for this. However, non-burning sunlight also has this effect. NIR radiation is able to penetrate light clothing and even penetrates through the skull. NIR also goes through sunblock, so you can be sun-safe and still get a good dose of healing NIR outdoors.
NIR exposure might be especially important post-op, when many people are confined indoors where they won’t receive NIR. Indeed, in the old days many hospitals had outdoor “rooms” so their patients could be in sunlight.
References
“Melatonin and the Optics of the Human Body” by S. Zimmerman and R. J. Reiter in Melatonin Research 2019, https://melatonin-research.net/index.php/MR/article/view/19/208
Sunlight
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