All posts in Arthritis

Curcumin

Daily supplements of curcumin may benefit cardiovascular health to the same extent as exercise for postmenopausal women (data from a clinical trial conducted in Japan and published in the journal Nutrition Research Nov 2012).

Vascular health, as measured by flow-mediated dilation (FMD), improved equally in groups of women receiving the curcumin supplements and those receiving aerobic exercise training.

Another study, published recently in the British Journal of Nutrition indicated that decreased FMD is reported to be a predictor of future adverse cardiovascular events, with every one percent decrease in FMD associated with a 12% increase in risk.

I recommend regular ingestion of curcumin to my patients with spinal stenosis, numbness and tingling, spinal degeneration, and now with this report I’ll suggest it as a preventive measure against cardiovascular disease in postmenopausal women. If a women can’t exercise curcumin is an alternative.

Curcumin has been linked to a range of health benefits, including potential protection against Alzheimer’s and protection against heart failure, diabetes and more.

The new study suggests that endothelial function may also be added to the list of potential benefits from curcumin.

Researchers from the University of Tsukuba recruited 32 post-menopausal women and assigned them to one of three groups: The first group acted as the controls, the second group underwent an aerobic exercise training regimen and the third group received a daily dose of 25 mg of curcumin.

The study lasted for eight weeks, after which the results showed that FMD increased significantly and equally by about 1.5% in both the exercise and curcumin groups, compared with no changes in the control group.

“The mechanism responsible for the curcumin-ingestion-induced improvement in endothelial function is unclear,” the researchers said.

“Curcumin exerts anti-inflammatory and antioxidative effects by inhibiting tumor necrosis factor-alpha (TNF-alpha), suggesting that its effect on endothelial function may be mediated by the suppression of inflammation and/or oxidative stress via down-regulation of TNF-alpha. However, TNF-alpha levels were not assessed in this study.

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Lupus

Lupus is a chronic disease that involves the immune system. It attacks healthy tissues and organs that can increase the risk of heart disease and cancer. Symptoms include extreme fatigue, skin rashes, and painful joints – simple movements can become painful from swollen joints.  

Current treatment is on how best to manage Lupus cases. Drug therapy includes Benlysta and according to the FDA, Benlysta research “suggested, but did not definitively establish” that the drug might reduce severe flare-ups of lupus symptoms. Benlysta has a high rate of serious infections and death in patients taking Benlysta compared to those taking a placebo. NOT MY FIRST CHOICE! Other drug choices include malaria medications and steroids. These have serious side effects too! 

A few years ago, Northern Ireland researchers at the University of Ulster conducted a study that tested fish oil, rich in omega-3 fatty acids, on more than 50 lupus patients.  After 24 weeks, researchers found a significant decline in disease measurements for those taking fish oil compared to placebo. Fish oil helped relieve fatigue, inflammation, skin rashes, and neurological problems. And all of that added up to improved quality of life — especially for those who were able to reduce their steroid use.

Adverse side effects: zero. 

I continue to recommend Metagenics EPA-DHA 720 as the omega 3 first choice.

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Gout

Gout pain is usually diagnosed when you have pain in the joint of your big toe (one of the typical spots where gout flares up). Gout occurs when uric acid crystals cause inflammation and swelling in tissue around joints. Those crystals form when high levels of uric acid build up. For most of us, uric acid normally dissolves in the blood and is passed out of the body in the urine. But for some, the body produces too much uric acid. In other patients, the body does a poor job of eliminating uric acid. In both cases the end result is the same: crystals form and pain develops. Gout can last for days.

I recommend gout patients eat cherries. It’s an old fashion remedy but eating cherries and drinking cherry juice helps relieve gout pains. The secret: Cherries help prompt uric acid excretion. Unfortunately, you might have to eat quite a few cherries before you start to feel relief. And cherries happen to be a natural laxative, so brace yourself for the repercussions. Meanwhile, there are other things you can do to help manage the excess uric acid:

Drink lots of water to help with elimination

 Two herbal therapies: Celery seed extract and extract of juniper

 Chiropractic treatments – especially gentle soft tissue therapy

 Yoga

 Avoid: High fructose corn syrup, heavy alcohol consumption, red meat, liver, kidneys, Shellfish and being overweight.

High-dose vitamin C promotes uric acid to be excreted into the urine. Start with 1-2 grams of vitamin C, three times daily. 

Hope this helps!

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Anti-Infammatory Diet Updates

 
Eating right and getting regular exercise is the best way to achieve and/or maintain health. I remember hearing Jack LaLanne say, “Diet is King & exercise is Queen, and when you put them both together you build a Kingdom.” 

Inflammation can be low-grade or it can flare up or progress into chronic or acute disease states, including serious autoimmune problems such as arthritis.  Although inflammation should lead to tissue repair and remodeling, when it becomes chronic, it prevents healing and should be viewed as a disease process. 

Nutritional imbalances  (deficiencies and excesses of various nutrients) can cause inflammation .

The Diet
The most important thing is too  eat fresh food, whatever it may be. Avoid packaged or processed foods—the more a food is processed, the less healthful it will be. Consume lots of plants. Plants have antioxidant properties and phytonutrients that quench inflammation.

Vegetables are always at the top of the list. Foods containing omega-3 fatty acids are also anti-inflammatory, including fish and, to a lesser extent, plant foods like flax seeds and walnuts.

Because plant-based foods are among the richest sources for powerful antioxidants and phenolics (including flavonoids) that reduce inflammation, the Mediterranean diet, which emphasizes fresh plant-based foods and phenolic-rich olive oil, has grown in popularity.

I recommend not eating  grains and enjoy high-fiber foods like beans, peas, lentils, oatmeal, nuts, and avocados. Consume more fish, especially salmon, tuna, and other fatty fish that contain those omega-3 fats.

Processed Foods and Meats

Avoid anything with more than a very small amount of sugar or high-fructose corn syrup, white flour products, sodas and sweet drinks, chips, and fried foods of all types, other than lightly stir-fried vegetables.

White flour increases inflammation.

Red meat isn’t necessarily bad. It is what we do to red meat that makes it bad for us by feeding cattle grains such as corn, instead of allowing them to eat the field grasses that they were intended to eat. An alternative to beef is buffalo or bison—these animals are grass-fed and, interestingly, will not eat corn.

For the carnivores among us, the preferred protein solution is buffalo or bison, grass-fed beef, organic chicken, and wild-caught fish, particularly salmon and tuna.

For those with rheumatoid arthritis: Increase EPA intake from marine sources such as oily fish (salmon, sardines, herring, trout, black cod) and oysters, aiming for consuming these foods several times a week, and to reduce dietary sources of arachidonic acid (meat, high-fat milk and cheese products, eggs) as much as possible. Make sure your diet is low in arachidonic acid and supplement with fish oils.

 

In a recent study at Lund University’s Antidiabetic Food Centre in Sweden, 44 healthy, overweight subjects aged 50 to 75 were fed an anti-inflammatory diet consisting of antioxidants, slow-release carbohydrates, omega fatty acids (oily fish), whole grains, probiotics, and viscous dietary fiber. After only four weeks, the results showed LDL cholesterol had dropped by 33 percent, blood lipids by 14 percent, blood pressure by 8 percent, and a risk marker for blood clots by 26 percent. A marker of inflammation in the body was also greatly reduced.5

A diet free of gluten has positive effects on symptoms and clinical signs of inflammatory diseases. Such a diet would be void of arachidonic acid, free of potentially allergenic wheat, dairy, and egg products, and high in plant-based antioxidants and other potentially anti-inflammatory phytonutrients.

What Sodas Bring to the Table
Soda is the beverage of choice for many Americans, especially children. In addition to the high sugar content, which causes blood sugar levels to spike, soda is loaded with phenylalanine and phosphate, which affect pH and deplete bone density. A 2007 study found that “The caramel content of both regular and diet drinks may be a potential source of advanced glycation end products, which may promote insulin resistance and can be proinflammatory.” In addition, “Consumption of one or more soft drinks per day was associated with increased odds of developing metabolic syndrome, obesity, increased waist circumference, higher blood pressure, hypertriglyceridemia, and low high-density lipoprotein cholesterol.”6

Supplement with anti-oxidants – these will stimulate the immune system, decrease platelet aggregation, modify cholesterol metabolism, reduce blood pressure, and possess anti-bacterial and antiviral activity. One of the most effective supplements I use for inflammation is using the UltraInflamX protein powder by Metagenics. This can be taken as 2 scoops with water or fresh juice twice daily. 

References

1. Seaman DR. Clinical nutrition for pain, inflammation, and tissue healing. Self published. 1998.

2. Seaman DR. The diet-induced pro-inflammatory state: A cause of chronic pain and other degenerative diseases. J Manip Physiol Ther. 2002; 25:168-179.

3. Adam O, et al. Anti-inflammatory effects of a low-arachidonic acid diet and fish oil in patients with rheumatoid arthritis. Rheumatol Int 2003 Jan;23(1):27-36.

4. Salas- Salvadó J, et al. Effect of a Mediterranean diet supplemented with nuts on metabolic syndrome status: one-year results of the PREDIMED randomized trial. Arch Intern Med. 2008;168(22):2449-2458.

5. Hafström I, et al. A vegan diet free of gluten improves the signs and symptoms of rheumatoid arthritis: the effects on arthritis correlate with a reduction in antibodies to food antigens. Rheumatol 2001;40(10):1175-79.

6.Dhingra R, et al. Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. Circulation 2007;116:480-88.

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Natural Pain Treatments That Work Best

 Everyone with chronic pain can safely start the Anti-inflammatory diet – no sugar, alcohol, gluten, dairy, preservatives, & chemicals. The minimum supplements I recommend you should be taking are high amounts of EPA/DHA (EPA-DHA 720, three softgels up to three times daily with food), Vitamin D3 (IsoD3 5,000 i.u. daily) and digestive enzymes (Metazyme, one tablet during each meal). Order from Metagenics 800-692-9400.

Additional Supplements for chronic pain:

Quercetin  (Resveratin Plus 12 capsules daily). Order from XYMOGEN 1-800-647-6100

UltraInflamX Plus 360 medical food is a shake that contains Turmeric, Ginger, Rosemary extract, as well as other vitamins and minerals plus 15 grams of protein. Two scoops in water or juice 1 – 2 times daily. Order from Metagenics 800-692-9400

Kaprex is for joint relief and contains hops, iso-alpha acids, Olive Leaf extract and Rosemary Leaf extract. Dose is two softgels three times daily. Order from Metagenics 800-692-9400.

Chronic pain depletes serotonin, GABA and dopamine and other catecholamines (which in turn amplify pain perception); so nutrients that address serotonin (such as Tryptophan, 5HTP, and vitamin D) and dopamine and catecholamines are useful. Trancor and Symphora (4 each per day). Order from Metagenics 800-692-9400

Acute Trauma: Traumeel tablets – take 1 tablet every 15 minutes for 3 hours then cut back to 1 every hour for day 1; 1 every 2 hours on day 2 and 1 3 per day until you come in for a visit. This is easily purchased in health food stores.

Peripheral neuropathy, including diabetic neuropathy:

Take Insinase  which contains Alpha Lipoic Acid 540 mg BID and  Acetyl-L-Carnitine HCL 400 mg BID. Order from Metagenics 800-692-9400.

 Osteoarthrits & RA:

UltraInflamX 360

Kaprex

EPA-DHA 720

Iso D3

Muscle Pain/Fibromyalgia:

Combinations of Magnesium, Calcium, Valerian root and Hops are essential. See my list for chronic pain and include UltraInflamX 360.

Capsaicin (Capsicum frutescens) cream:

Capsaicin is the main component in hot chili peppers (also known as cayenne). Applied to the surface of the skin, it is believed to deplete stores of a substance that contributes to inflammation and pain in arthritis. Several studies have shown that capsaicin cream provided much better pain relief than a placebo but no improvement in joint swelling, grip strength, or function for people with OA. Pain reduction generally begins 3 to 7 days after applying the capsaicin cream to the skin. Apply the cream 4 times daily.

Biofreeze gel:

This is another topical pain reliever used in pain management. This is especially good for sore or strained muscles; shoulderand arm pain; neck, hip, and leg pain; back pain; arthritis pain; painful joints; diabetic neuropathy; tendonitis; and bursitis. Biofreeze needs to be applied 4 times daily.

KinesioTaping procedures are an invaluable aide in everything from chronic edema (swelling) reduction to reduction of muscle tension/pain.

My two favorite modalities for chronic pain continue to be the Deep Muscle Stimulator (DMS) and warm laser.

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Polymyalgia rheumatica

Conventional medical treatment for polymyalgia rheumatica is steroids (prendisone). It is considered an autoimmune dysfunction. Many of you know I feel autoimmune dysfunction is very frequently the result of dietary factors.
I believe that a more productive approach to this condition might  be a
10 day or 28 day elimination diet, this doesn’t mean fasting. I use anti-inflammatory foods and medical food shakes. 
Some people after the elimination diet chose to follw it up by adding one low glycemic vegetable each morning, on an empty stomach, to see if there is any reaction. If pain returns, I would suggest a period of at least three days without adding any new foods – longer if pain persists.

I have recommended the paleo diet to some clients with PR.

There are some Doctors that feel every autoimmune condition has turned out to have some version of a leaky gut/molecular mimicry connection. 
For any autoimmune condition:
Gluten-free alone is not enough.
Lowish carbs, which may increase TSH, but that doesn’t mean it’s
pathological.
Carbs should be mostly glucose, not much fructose, so mostly roots, tubers,
vegetables, bulbs, but limit fruits.
Peel your vegetables whenever possible because most plant-protective
anti-nutrients are found in the peel.
Forbidden for life:
All cereal grains: Wheat (spelt, einkorn, durum, emmer, kamut), barley,
rye, triticale, oats, rice, corn, maize, wild rice, sorghum, millet, teff,
amaranth, buckwheat, fonio, breadnut, cockscomb, cattail, chia, wattleseed
(acacia), Goosefoots (quinoa, pitseed, kañiwa)
Dairy of any kind.
Nuts and seeds of any kind.
NSAIDs of any kind.
Nightshades (tomato, pepper, eggplant, potato).
Alcohol.
Antacids that contain aluminum hydroxide.
Oral contraceptives.
Iodine (if you have Hashimoto’s).
Legumes

I agree with all these items but I am not sure about eggs. Eggs are a paleo food but I know eggs are considered a highly allergic food. The problem with eggs is what the birds are fed.  If they are fed corn and soy (which almost all are) that could cause all sorts of reactions in people. Most chickens, even if labeled “free range” are fed corn and soy. 

Make sure the thyroid levels checked. Symptoms of all sorts of myalgias are frequently untreated or undertreated hypothyroidism.  Don’t fall prey to tyranny of TSH only test –  “normal” range is far too wide.  Symptomatic people with TSH of over 1.5 likely have a problem.  Free T3 and Free T4 levels as well as all antibodies should be checed as well.   A short trial course of natural thyroid such as Armour or Naturthroid etc  (not Synthroid or other T4 only synthetics) to see if symptoms  improve is far safer (and cheaper) than longterm prednisone.  Not convinced? Read
Broda Barnes’ MD’s classic book on this topic as well as Mark Starr MD’s
newer classic.  Barnes also advocated a low-carb (albeit not necessarily
paleo) diet for hypothyroid conditions.

I can think of one patient who had PR.  She started on the 10 day elimination diet and used the Opticleanse GHI shakes by Xymogen. After that she only ate  grass fed beef and lamb. She ate no pork, poultry or fish. She also only ate sweet potatoes, yams and squash. She ate NO fruit or ANYTHING else. She also sunned herself daily for 1/2 hour. In 2-3 months all the
symptoms went away.  It was a very restrictive diet, however, it worked.

Your choice, try prednisone or diet with XYMOGEN Opticleanse GHI!

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Diets That Promote Arthritis & Diets That Promote Healthy Joints

Diets high in processed foods, sweets, sugars,  baked breads, chips, cookies and pastries all promote inflammation which promotes arthritis. A menu too high in omega-6 fatty acids (soy, safflower, sunflower, corn oils), and  trans-fats (hydrogenated and partially hydrogenated fats) also promote inflammation. Furthermore, diets like the above tend to be too high in calories, upset blood sugar balance and lead to weight gain. Being overweight greatly increases the stress on the low back, hip and knee joints. 

Conversely, diets high in relatively unprocessed, low-temperature-cooked (even raw) foods rich in omega-3 fatty acids (chia and flaxseed, walnuts, fatty fish, grass fed meats) and high antioxidant foods (fruits, vegetables, beans, herbs, spices and tea) are anti-inflammatory.

There are other nutrients that may promote joint health. Glucosamine and chondroitin are well-known. Gelatin, MSM (a naturally occurring sulfur compound in our diets), vitamin D, folic acid and B12 may play a role as well. 

My favorite medical food shake for joint inflammation is UltraInflamX 360 by Metagenics. 

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Vitamin D Update From the Annual Congress of the European League Against Rheumatism

June 16-19, 2010 in Rome, Italy — vitamin D deficiency is a common feature in patients with a range of painful rheumatic and related autoimmune disorders. What is less clear, however, is the amount of vitamin D supplementation that would benefit these patients.

Here are highlights from three recent studies:

  1. Researchers in the UK assessed levels of vitamin D in patients with either inflammatory joint diseases (ie, rheumatoid arthritis, RA), osteoporosis, or unexplained muscle pain (ie, myalgia) — 30 subjects in each group — compared with a control group of 90 patients with chronic back pain [Kelly et al. 2010]. Within all 180 patients (two-thirds female) the median vitamin D level was 15 ng/mL and 58% were below the normal range (defined as 20-58 ng/mL by these authors). The median vitamin D level in control patients (with back pain) was 20 ng/mL compared with statistically significant lower medians of 14 ng/mL in the RA group, 12 ng/mL in the osteoporosis group, and 12 ng/mL in the myalgia group. The authors expressed surprise that vitamin D deficiencies also were evident in persons with diffuse muscle pain but suggested that patients in all groups would benefit from vitamin D supplementation. Note: Why patients with back pain were chosen as a control group is unclear, as other research has already found such patients to be vitamin D insufficient (ie, <30 ng/mL) overall.
  2. A second study, conducted by Italian researchers, focused on 1,191 patients (85% female) with rheumatoid arthritis (RA) to determine a correlation between vitamin D deficiency and several clinical measures of disease activity [Idolazzi et al. 2010]. They found that levels of 25(OH)D were deficient (<20 ng/mL) in 52% of the patients not taking a vitamin D supplement and in one third of those taking supplements (?800 IU/day). In non-supplemented patients low levels of 25(OH)D significantly correlated with worse scores on 3 measures of disease activity: Health Assessment Questionnaire Disability Index, Mobility Activities of Daily Living Score, and Number of Swollen Joints Count. Significantly lower 25(OH)D levels were found in patients with active disease compared with those in disease remission and in those who were not responding to treatment compared with patients with a good response. Therefore, vitamin D sufficiency appears to be directly related to the course of rheumatoid arthritis and response to treatment; however, the authors conclude that further research is needed to assess the benefits of vitamin D supplementation in these patients.
  3. Another reported study from Italian researchers evaluated the impact of vitamin D supplementation in patients with either inflammatory autoimmune disease (IAD; rheumatoid arthritis, spondyloarthritis, or connective tissue diseases; n=43) and noninflammatory autoimmune disease (NIAD; osteoarthritis or osteoporosis; n=57) [Sainaghi et al. 2010]. Mean 25(OH)D levels between the two groups at outset were equivalently deficient — 12.6±7.5 ng/mL IAD group, 13.1±8.8 ng/mL NIAD group. Following daily supplementation with 800 to 1000 IU of vitamin D3 for 6 months, only 29% of all patients reached 25(OH)D levels ?30 ng/mL considered to be sufficient and there were no significant differences observed between the IAD and NIAD groups. The authors conclude that, while the amount of supplementation was not adequate to normalize 25(OH)D levels in their patients the response to vitamin D (or lack thereof) did not appear to be influenced by the presence of an inflammatory autoimmune condition.

COMMENTARY: A separate presentation at EULAR 2010, based on a large multinational survey of women with RA, reported that among the 75% who were taking analgesic medications more than 7 in 10 (72%) still experienced daily pain [Strand et al. 2010]. Two-thirds of the respondents said that they constantly look for new ideas to address pain. Therefore, the studies above are of great importance because they demonstrate that painful inflammatory and noninflammatory rheumatologic or bone conditions are generally accompanied by vitamin D deficiencies. Based on prior research, it is not surprising that daily supplementation of 800 to 1000 IU of vitamin D3 was inadequate to significantly raise 25(OH)D to more normal levels. It is disappointing that none of the 3 research teams proceeded to the next step of testing more ample vitamin D supplementation and assessing outcomes on pain relief and/or disease moderation.

REFERENCES: 
Idolazzi L, Bagnato G, Bianchi G, et al. Vitamin D deficiency in rheumatoid arthritis: prevalence, determinants, and associations with disease activity. A cross-sectional study. Ann Rheum Dis. 2010;69(Suppl 3):516. Abstract SAT0093.
Kelly C, Scott K, Bell G, et al. Vitamin D levels in a spectrum of rheumatic disease. Ann Rheum Dis. 2010;69(Suppl 3:481. Abstract FRI0509.
Sainaghi PP, Bellan M, Carda S, et al. Response to vitamin D supplementation in inflammatory autoimmune diseases: a retrospective study. Ann Rheum Dis. 2010;69(Suppl 3):652. Abstract SAT0506.
Strand V, Emery P, Fleming S, Coke E. The impact of rheumatoid arthritis on women: focus on pain, productivity, and relationships. Ann Rheum Dis 2010;69(Suppl 3):748. Abstract OP0002-PARE.

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Laser Treatments

Laser therapy has been around for a long time but it is considered cutting edge treatment for musculoskeletal injuries and pain.
Laser therapy stimulates cellular activity, expediting the healing processes to reduce inflammation and repair damaged tissue. 

You can feel the warm deep tissue penetration. This deep heat significantly increases the body’s cellular production of ATP (Adenosine-triphosphate) to reduce inflammation and heal the inflamed area.

Here are some of the benefits of using the deep tissue penetration that laser provides safely and effectively:

Healing and pain relief with no side effects, drug interaction effects, or invasive surgery.

Treats acute and chronic conditions as well as post surgical pain.

Pain relief is often felt immediately.

Most laser treatments take only 10-20 minutes.

Are you a potential candidate?

  • If you have pain that is of musculo-skeletal origin, laser therapy may be for you:
    This includes sports injuries, back and neck pain, any joint pain (knee, shoulder, ankle, etc), bursitis, tendonitis, tennis elbow, contusions, strains and sprains, carpal tunnel syndrome, chondromalacia patellae, arthritis, fibromyalgia, heel spurs, plantar fascitis, migraine headaches, neck pain/whiplash, nerve root pain, postoperative pain, repetitive stress injuries, TM joint pain and more.
  • If you have the wound that is slow to heal and has been resistant to treatment, you may be a candidate for laser therapy. This includes slow healing fractures, as well as soft tissue injuries and ulcers.
  • If you have multiple trigger points (sore spots in the muscles) that do not go away, you may be a candidate for laser therapy. This includes areas associated with fibromyalgia.
  • If you have had Prolotherapy or PRP, and wish to accelerate the response of healing, you may be a candidate for laser therapy. This includes any area that has been treated with Prolotherapy/PRP injections.
  • If you need Prolotherapy or PRP therapy but are afraid of needles, you may be a candidate for laser therapy.
  • Laser therapy stimulates the same areas that Prolotherapy targets. It does it without needles, but requires a lot more time and repeated treatments to gain the result that can be gotten from Prolotherapy and laser together.

Feel free to call me directly at 310-473-2911 or call my cell phone at 310-339-0442

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Antidepressant Duloxetine for Treatment of Back Pain – Not!

The FDA has approved duloxetine hydrochloride (Cymbalta, manufactured by Eli Lilly) an antidepressant, to treat chronic back pain and osteoarthritis pain. The FDA granted the new indication based on results of four double-blind, placebo-controlled, randomized clinical trails in which patients randomized to duloxetine reported a greater reduction compared with the placebo group. 

In addition to its use for treatment of depression, duloxetine is approved for treatment of diabetic peripheral neuropathy, generalized anxiety disorder, and fibromyalgia.

Are you ready for this?: The most common side effects reported in the back pain and osteoarthritis trials were nausea, dry mouth, insomnia, drowsiness, constipation, fatigue, and dizziness. Other serious side effects, which occurred in less than 1% of patients, included liver damage, allergic reactions such as hives, rashes and/or swelling of the face, pneumonia, depressed mood, suicide, and suicidal thoughts and behavior. I have patients who come in with insomnia, drowsiness, constipation, fatigue, and dizziness as there chief complaints – who needs additional side effects.

Here’s my thoughts – try the anti-inflammatory diet, UltraInflamX 360, and fish oils for 12 weeks and feel the improvement without the side effects.
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