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      Dietary Ingredients as an Alternative Approach for Mitigating Chronic Musculoskeletal Pain: Evidence-Based Recommendations for Practice and Research in the Military

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          Abstract

          Objective

          Approximately 55–76% of Service members use dietary supplements for various reasons, including pain and related outcomes. This work evaluates current research on dietary ingredients for chronic musculoskeletal pain to inform decisions for practice and self-care, specifically for Special Operations Forces personnel.

          Methods

          A steering committee convened to develop research questions and factors required for decision-making. Key databases were searched through August 2016. Eligible systematic reviews and randomized controlled trials were assessed for methodological quality. Meta-analysis was applied where feasible. GRADE was used to determine confidence in the effect estimates. The committee made evidence-informed judgments and recommendations for practice and self-care use.

          Results

          Nineteen eligible dietary ingredients were assessed for quality, efficacy, and safety. Avocado soybean unsaponifiables, capsaicin, curcuma, ginger (as a food source), glucosamine, melatonin, polyunsaturated fatty acids, and vitamin D were conditionally recommended as their benefits outweighed risks, but there was still some uncertainty about the trade-offs. No recommendations were made for boswellia, ginger (as a dietary supplement), rose hip, or s-adenosyl-L-methionine. Recommendations were made against the use of collagen, creatine, devil’s claw, l-carnitine, methylsulfonylmethane, pycnogenol, willow bark extract, and vitamin E. Research priorities were developed to address gaps precluding stronger recommendations.

          Conclusions

          Currently the scientific evidence is insufficiently robust to establish definitive clinical practice guidelines, but processes could be established to track the impact of these ingredients. Until then, providers have the evidence needed to make informed decisions about the safe use of these dietary ingredients, and future research can address existing gaps.

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          Most cited references21

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          Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet.

          Lead, mercury, and arsenic have been detected in a substantial proportion of Indian-manufactured traditional Ayurvedic medicines. Metals may be present due to the practice of rasa shastra (combining herbs with metals, minerals, and gems). Whether toxic metals are present in both US- and Indian-manufactured Ayurvedic medicines is unknown. To determine the prevalence of Ayurvedic medicines available via the Internet containing detectable lead, mercury, or arsenic and to compare the prevalence of toxic metals in US- vs Indian-manufactured medicines and between rasa shastra and non-rasa shastra medicines. A search using 5 Internet search engines and the search terms Ayurveda and Ayurvedic medicine identified 25 Web sites offering traditional Ayurvedic herbs, formulas, or ingredients commonly used in Ayurveda, indicated for oral use, and available for sale. From 673 identified products, 230 Ayurvedic medicines were randomly selected for purchase in August-October 2005. Country of manufacturer/Web site supplier, rasa shastra status, and claims of Good Manufacturing Practices were recorded. Metal concentrations were measured using x-ray fluorescence spectroscopy. Prevalence of medicines with detectable toxic metals in the entire sample and stratified by country of manufacture and rasa shastra status. One hundred ninety-three of the 230 requested medicines were received and analyzed. The prevalence of metal-containing products was 20.7% (95% confidence interval [CI], 15.2%-27.1%). The prevalence of metals in US-manufactured products was 21.7% (95% CI, 14.6%-30.4%) compared with 19.5% (95% CI, 11.3%-30.1%) in Indian products (P = .86). Rasa shastra compared with non-rasa shastra medicines had a greater prevalence of metals (40.6% vs 17.1%; P = .007) and higher median concentrations of lead (11.5 microg/g vs 7.0 microg/g; P = .03) and mercury (20,800 microg/g vs 34.5 microg/g; P = .04). Among the metal-containing products, 95% were sold by US Web sites and 75% claimed Good Manufacturing Practices. All metal-containing products exceeded 1 or more standards for acceptable daily intake of toxic metals. One-fifth of both US-manufactured and Indian-manufactured Ayurvedic medicines purchased via the Internet contain detectable lead, mercury, or arsenic.
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            Long-term consequences of chronic pain: mounting evidence for pain as a neurological disease and parallels with other chronic disease states.

            Perry Fine (2011)
            This article reviews the potential physical and psychological consequences of chronic pain and the importance of implementing effective therapeutic strategies to mitigate the harms associated with inadequate treatment. A review of recent literature examining the neurobiology and pathophysiology of chronic pain reveals that this highly prevalent condition negatively impacts multiple aspects of patient health, including sleep, cognitive processes and brain function, mood/mental health, cardiovascular health, sexual function, and overall quality of life. Furthermore, chronic pain has the capacity to become increasingly complex in its pathophysiology, and thus potentially more difficult to treat over time. The various health complications related to chronic pain can also incur significant economic consequences for patients. Like other chronic conditions, it is important that chronic pain is managed with the objective of minimizing or avoiding its associated long-term sequelae. In line with this approach, early and effective multimodal treatment strategies, including analgesic therapy that controls pain intensity, are essential to improving outcomes and returning patients to normal levels of function. Wiley Periodicals, Inc.
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              The well-built clinical question: a key to evidence-based decisions.

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                Author and article information

                Journal
                Pain Med
                Pain Med
                painmedicine
                Pain Medicine: The Official Journal of the American Academy of Pain Medicine
                Oxford University Press
                1526-2375
                1526-4637
                June 2019
                15 April 2019
                15 April 2019
                : 20
                : 6
                : 1236-1247
                Affiliations
                [1 ]Consortium for Health and Military Performance, Department of Military & Emergency Medicine, F. Edward Hébert School of Medicine, Uniformed Services University, Bethesda, Maryland, USA
                [2 ]The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
                [3 ]Thought Leadership and Innovation Foundation, McLean, Virginia, USA
                [4 ]Division of Health Promotion, University of Applied Sciences Coburg, Coburg, Germany
                [5 ]Institute of Medical Psychology, Ludwig Maximilian University of Munich, Munich, Germany
                Author notes
                Correspondence to: Courtney Boyd, MA, Consortium for Health and Military Performance, 6720B Rockledge Dr., Suite 605, Bethesda, MD, 20817 USA. Tel: 571-310-1197; E-mail: courtney.boyd.ctr@ 123456usuhs.edu .
                Article
                pnz040
                10.1093/pm/pnz040
                6544555
                30986309
                d524f62c-9b26-4e84-b559-f02ed3d40924
                © 2019 American Academy of Pain Medicine.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contactjournals.permissions@oup.com

                History
                Page count
                Pages: 12
                Funding
                Funded by: Preservation of the Force and Family Behavioral Health Program, Uniformed Services University
                Award ID: Award No. HU0001-15–2-0053)
                Categories
                INTEGRATIVE MEDICINE SECTION
                Review Article

                Anesthesiology & Pain management
                systematic review,meta-analysis,dietary ingredients,dietary supplements,chronic pain,musculoskeletal pain

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