symptoms. Additionally the drugs have different
times to onset of action. Ibuprofen reaches maxi-
mum efficacy in a matter of days; chondroitin is
maximally effective over a few weeks. Chondroitin
is typically sold in varying combinations with glu-
cosamine, manganese, and magnesium; however,
no data suggests the combination treatment to be
more effective than the single agent alone.- Toxicity: Mild GI distress is the most common side
effect. Combination tablets can exceed safe daily
doses of manganese and cause central nervous
system (CNS) irritability. Chondroitin has a hepari-
noid structure and may predispose to bleeding if
used in with other anticoagulants. - Regulated/Banned: No.
- Conclusion: Though less convincing than glu-
cosamine (see below) some evidence supports
chondroitin use in OA. Several studies with 5+
years of follow-up report no adverse events related
to chondroitin use. Given the moderately high cost
of chondroitin tablets, a 6–8 week trial period is
advisable. If no clinical effect is noted during this
trial, chondroitin should be discontinued as a result
of cost considerations.
- Spinal manipulation (Andersson et al, 1999; Koes et al,
1996; Assendelft et al, 1995)
- Primary use: Relief of low back pain/stiffness, relief
of DOMS, and speeding return to play following
low back injury. - Evidence: Majority of evidence suggests spinal
manipulation to be at least as effective as conven-
tional treatment for low back pain. Nine of ten
well-designed RCTs in a recent review concluded
that spinal manipulation provided more pain relief
than control treatments; however, differences
between manipulation techniques make conclu-
sions difficult to generalize. Manipulation may
require more physician visits than conventional
care, increasing the cost of therapy. Health insurers
may reimburse some of this cost. - Toxicity: Rare case reports of stoke, paralysis, or
spinal chord damage are mostly related to c-spine
manipulation and occur at a frequency of one per
million of manipulations. No severe complications
have been reported from over 15,000 patients
enrolled in monitored RCTs. - Regulated/Banned: No.
5.Conclusion: Competently performed L-spine manip-
ulation is safe and likely effective for low back pain,
although it may be higher cost than other therapies.
•Panax* Ginseng (Allen et al, 1998; Wesnes et al,
2000; Ellis and Reddy, 2002; Yun and Choi, 1998) - Primary use: Improve cognitive function, athletic
performance, and increase energy. - Evidence: Many studies document that ginsengsup-
plementation has no ergogenic effects. Similarly, P.
ginsenghas not been shown to improve memory
when used alone, but has been demonstrated to have
efficacy when combined with ginkgo supplementa-
tion in middle-aged individuals.
3.Toxicity: Insomnia, tachycardia and palpitations
become more common with high doses. Mastalgia,
vaginal bleeding, and amenorrhea are likely related to
the estrogenic effects of ginseng. Long-term use is
not well studied. Ginsengwill intensify the effects of
other common stimulants (caffeine, guaraná, and tea). - Regulated/Banned: No.
- Conclusion: Studies suggest minimal toxicity with
short-term use, but long-term use is more difficult
to justify since estrogenic risks may outweigh the
unclear benefits; however, further studies continue
to explore many other possible indications for gin-
sengsupplementation.
Promote
- Glucosamine sulfate (Pavelka et al, 2002; Thie, Prasad,
and Major, 2001; Foerster, Schmid, and Rovati, 2000;
McAlindon et al, 2000)
- Primary use: Relief of stiffness and pain in OA and
temperomandibular joint dysfunction(TMJ).
2.Evidence: Multiple trials consistently demonstrate
superior efficacy of glucosamine sulfate to placebo.
More recent data suggest that glucosamine may
provide more pain relief than nonsteroidal anti-
inflammatory drugs(NSAIDs) after 6 weeks of use.
Insufficient data exists to determine if glucosamine
slows the rate of OA progression. Knee OA is the
most widely studied, but efficacy data also exists for
glucosamine in TMJ and OA of the hand and spine. - Toxicity: Mild GI distress (comparable to placebo
levels) has been reported. Concerns for exacerba-
tions of diabetic control or reactions in patients
with shellfish allergy appear to be unfounded. - Regulated/Banned: No.
- Conclusion: Glucosamine is an effective treatment
for OA. Glucosamine supplementation should be
discontinued if no clinical response occurs after a
6–8 week trial due to its moderate cost.
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Aaron RK, Ciombor DM, Jolly G: Stimulation of experimental
endochondral ossification by low-energy pulsing electromag-
netic fields. J Bone Miner Res 4:227–233, 1989.
Allen JD, McLung J, Nelson AG, et al: Ginseng supplementation
does not enhance healthy young adult’s peak aerobic exercise
performance. J Am Coll Nutr 17(5):462–466, 1998.458 SECTION 5 • PRINCIPLES OF REHABILITATION