Arthritis

Description

Arthritis is a disease of the joints characterized by pain, swelling, redness, heat and, sometimes, structural changes. This condition is more common in women than in men. Arthritis may result from another condition, be associated with another condition, or simply develop on its own. The two most common forms of this disease are osteoarthritis and rheumatoid arthritis.

Osteoarthritis, a degenerative joint disease and the most common form of arthritis and joint disorders, is the gradual deterioration of cartilage, usually in the larger, weight-bearing joints such as the hips, knees, and spine. This wear and tear is a normal process predominantly found in people age 55 and older. Among those younger than 45, it occurs more often in men. After that age, women contract this disorder more often. By the eighth decade of life, approximately 90% of all people are affected by osteoarthritis. Since this is a natural part of aging, beyond a certain age most people will almost certainly contract the disease, even if the symptoms are not detected.

Although the joints are not always inflamed, the articular cartilage may begin to flake and crack, due to overuse or injury.

In severe cases the underlying bone becomes thickened and distorted. Scar tissue may then replace damaged cartilage.

If movement becomes painful and restricted, lessened use of the associated muscles will lead to their atrophy.

Rheumatoid arthritis is a chronic joint disease affecting one or more joints; the synovium gradually becomes inflamed and swollen. Inflammation may occur in other parts of the joints as well. Gradual weakening of the bones comprising the joint occurs in persistent cases of rheumatoid arthritis. Tissue destruction occurs in the most severe cases. The most commonly affected joints are those of the hands and feet, particularly those of the knuckle and toe joints. The wrists, knees, ankles, and neck are also frequently affected.

Rheumatoid arthritis may occur as a single mild attack, or as several episodes which can leave the victim increasingly disabled. In extremely few persons, rheumatoid arthritis causes extensive deterioration of joint and bone tissues, producing deformities of the affected and surrounding areas. Damage to the lungs, heart, nerves and eyes can also occur, making it difficult to lead an active, normal life. This form of arthritis can affect people of any age, including juveniles, but predominantly affects those between the ages of 40 and 60. Slightly less than one-half of affected individuals have complete remission.

Approximately one in ten individuals is severely disabled.

Management of Arthritis

Diagnosis is made by a physician, who will not only take a careful history of the symptoms, but also do a proper physical examination to elicit the signs of arthritis and the functional status of the joints. Not infrequently, the physician will do certain laboratory tests to complete the study. The common ones are: a complete blood count, a urinalysis, a sedimentation rate (ESR), test for rheumatoid factor and antinuclear antibodies, synovianalysis (examination of the joint fluid) and X-rays of the affected joints. These tests are used both for the establishment of diagnosis and for the progress of therapy.

Prevention of arthritis (A Joint Protection Program)

Individuals who are genetically predisposed to getting arthritis (i.e., "it runs in the family") can fend off symptoms of severe arthritis by regulating their body weight, and by seeking physical or occupational therapy for newly affected joints.

Treatment

There are four primary objectives in the treatment of arthritis: reduction of inflammation and pain; preservation of the joint's function prevention of deformity; and treatment of the cause (if known).

The best treatment is to remove weight from the joints. This may entail using a walking stick, going on a balanced weight reduction diet, sleeping on a bed which properly conforms to the shape of the body and getting frequent rest.

Regular exercise, both active and passive, will keep the affected muscles from weakening. The individual may benefit from a hydrotherapy program under trained supervision. Heat and cold applications to the joint may induce muscle relaxation and an analgesic effect.

Aspirin is commonly used as a painkiller as well as other nonprescription pain-relievers.

However, because of individual sensitivity to side effects (aspirin, for example, can cause gastrointestinal bleeding), the physician may try several drugs to determine which has the least, or no deleterious effects: nonsteroidal anti-inflammatory drugs, such as Indomethacin; corticosteroids; and (in the case of rheumatoid arthritis) antimalarials, gold salts, penicillamine, plus experimental cytotoxic drugs.

Surgical removal of badly inflamed joint synovium may be required. Common types of surgery are: synovectomy (removal of the synovial membrane), arthroplasty (for realignment and reconstruction), repair of tendon rupture, arthrodesis (fusion of the joint). Some joints may be artificially replaced.

Alternative treatments exist which are not universally accepted: acupuncture; chiropractic; and nutritional, herbal or folk therapy.

Causes

Osteoarthritis

Primary Factors
The primary cause of osteoarthritis is wear due to aging. There may be reduced biomaterial properties due to normal processes or disturbances in cartilage metabolism from:

Diabetes
Acromegaly
Ochronosis


Predisposing Factors
Macrotrauma, especially common in athletes involved in contact sports
Microtrauma
Inactivity


Rheumatoid arthritis

Primary Factors
The primary cause of rheumatoid arthritis is not known with any certainty. It is speculated an autoimmune process due to a viral infection may be involved.

Signs & Symptoms

All forms of arthritis

Swelling	Pain
Tenderness	Redness
Stiffness in one or more joints

Osteoarthritis

Episodic pain
Episodic swelling and stiffness in the nearby muscles, occurring at intervals of months or years
Disturbed sleeping
Inability to perform everyday tasks

Often the painful area is not that which is affected. This is called "referred pain," and can be a deceptive problem in diagnosis.

Rheumatoid arthritis

Usually begins without symptoms. After a few weeks or months, a person may show the following symptoms:

Illness	Fever
Listlessness	Fatigue
Anorexia	Weight loss
Vague muscle pain

Late Characteristic Symptoms (may appear suddenly)

Redness	Swelling
Tenderness upon touching	Pain in moving
Bursitis	Anemia
Muscle atrophy	Tremor

Early morning stiffness which may subside with movement

Note: Damp weather and emotional stress do not cause arthritis but may enhance the symptoms.

Nutritional Supplements

Structure & Function: Joint Support

---------------------------------
General Supplements
---------------------------------

	Adult	Child/Adolescent
Beta Carotene*
Boswellic Acid	300 mg	300 mg
Collagen Type II	2,000 mg	2,000 mg
DHEA*
DLPA	500 - 2,000 mg	100 - 1,000 mg
EPO	2 - 3 g	1 - 2 g
Fish Oils	6 - 10 g	3 - 4 g
Glucosamine S*
Manganese	5 - 20 mg	2 - 5 mg
Selenium	100 - 300 mcg	20 - 100 mcg
SOD*
Tart Cherry	900 mg	900 mg
Vitamin B-6	25 - 100 mg	5 - 20 mg
Vitamin E	400 - 1,200 IU	200 - 800 IU
White Willow Bark	240 mg	240 mg
Zinc	20 - 100 mg	10 - 30 mg

* Please refer to the respective topic for specific nutrient amounts.

Notes:

There has been a virtual explosion of interest concerning the efficacy of antioxidants in arthritic conditions. Some combinations call for six, eight, or even more, such nutrients to be taken together.

This has extended the number of antioxidants commonly available, some of which are reputed to be many times more powerful than vitamin C.

The first list includes: manganese, selenium, zinc and vitamin E. To this list may now be added: vitamin B15, niacinamide, vitamin C, bioflavonoids, Beta Carotene, pycnogenol, sulfur and superoxide dismutase.

The most exciting development has been with Collagen Type II and Hyaluronic Acid in combination with additional, naturally occurring anti-inflammatory components of Marine Lipid Concentrate (Fish Oil), Boswellic Acid Concentrate (Boswellia Serrata), White Willow Bark, and Tart Cherry extract. This appears to be at least as effective as the ubiquitous NSAIDs without the side effects! In fact, this combination is showing extraordinary promise as a therapeutic alternative to replace the dangerous COX-2 inhibitor drugs being pulled from the market (Vioxx, Celebrex).

The combination of Collagen Type II, hyaluronic acid and the natural anti-inflammatories fish oil, boswellic acid, white willow bark and tart cherry are only available in the Applied ProLine product called CR Pro⁷.

The hormone DHEA has been excitedly received in some quarters for reversing the aging process, part of which seems to be arthritic conditions.

For those who like to increase their consumption of natural plant foods, chlorella and wheat grass juice may prove to be beneficial. Ideally, as a boost to the immune system, freshwater blue-green algae should be combined with enzymes to enhance the breakdown of the protein cell walls during the digestion process, thereby saving energy for other functions. A well-designed enzyme profile will additionally assist in the nutrient absorption of the algae into the bloodstream. This combination has been proven to instigate aggressive behavior in white blood cells for a six hour period following consumption of the nutrients. The white blood cells are the "worker bees" of the immune system, tracking down, identifying invading viruses and bacteria, and destroying them with extreme prejudice. For a strong immune system you must first start with a strong Foundation, combining the best features of potent nutritional content from algae with the catalyst benefits of enzymes.


Note: All amounts are in addition to those supplements having a Recommended Dietary Allowance (RDA). Due to individual needs, one must always be aware of a possible undetermined effect when taking nutritional supplements. If any disturbances from the use of a particular supplement should occur, stop its use immediately and seek the care of a qualified health care professional.

Nutrient Depletion

Arthritis medications may rob your body of important nutrients, including:

Vitamin C NSAID drug therapy (including aspirin) can cause urinary excretion of vitamin C. This important vitamin is essential for maintaining connective tissue and synthesizing collagen, a protein and primary constituent of connective tissue. It also plays a role in the body's healing process by enhancing the immune system and aiding in the prevention of infections. Low levels of vitamin C are common in sufferers of rheumatoid arthritis (RA).

Calcium Corticosteroids can reduce dietary calcium, vital for nerve, muscle, and bone functioning. Reduced levels can increase the risk of osteoporosis. Low levels of calcium might cause aching joints, muscle cramps, extremity numbness, and is a common deficiency in R-A sufferers.

Vitamin E This antioxidant is essential in protecting the body's cellular membranes and aiding in the body's healing process.

Zinc Low serum levels of zinc are common in people taking corticosteroid medication and in those suffering from RA. This key mineral in the body is a constituent in the enzyme synthesis of collagen.

Arthritis medications may also affect the levels of Vitamin D, Folic Acid, & Selenium.

References:

Mahan, K. & Escott-Stump, S: Krause's Food, Nutrition and Diet Therapy. Saunders, 1996.

Walji, Hasnain. 1994. Arthritis & Rheumatism - Orthodox & Complementary Approaches Hodder Headline Plc. London.

Drug Interactions

Drugs are the primary allopathic therapy to control the pain and inflammation associated with Rheumatoid Arthritis.

Most of the drugs diminish the production of prostaglandins, produced by the inflammatory process. [Vitamin E is a natural prostaglandin inhibitor.]

Today, the first line of attack comprises NSAIDs (Nonsteroidal anti-inflammatory drugs) including salicylates. More exotic drugs may also be resorted to in desperation: antimalarial agents, gold salts, penicillamine, steroids and immunosuppressive agents.

Side effects frequently include nutritional status.

Aspirin, for example, increases urinary excretion of vitamin C. Decreased vitamin status with respect to vitamin C as well as folate have been noted. There may also be extensive bleeding both with salicylates and other NSAIDs. An associated condition is anemia.

Methotrexate and Sulfasalazine (both used as NSAIDs) are associated with the greatest losses of folate and these drugs should be accompanied with daily supplements of folate.

Corticosteroids are the most potent drugs but are mostly reserved for the worst cases as the side-effects are so severe. Nutritionally, they can produce a negative nitrogen balance, so that protein is lost and muscle tissues waste away. There is also reduced calcium absorption, so that bones become soft and weak.

Penicillamine (like gold salts) may both cause proteinuria but with penicillamine there may also be depletion of minerals: zinc, copper and iron.

Dietary Considerations

In the case of osteoarthritis, stress on the joints can be alleviated with a Weight Reduction Diet to shed excess pounds. This is an important management strategy since inactivity produced by progressive joint degeneration will result in weight gain and further stress.

Steroids are often prescribed to relieve the inflammation and pain associated with rheumatoid arthritis. These drugs can cause retention of sodium and water, and demineralization of bones resulting in osteoporosis and fractures. A Sodium Restricted Diet and calcium supplements may remedy these conditions.

There is no conclusive evidence that nutritional deficiencies cause arthritis, nor that food supplements affect the outcome of arthritis. Fat-soluble vitamins were long considered aids in the management of arthritis; as yet, there is no proof to substantiate this claim.

Homeopathic Remedy

1.* Rhus Toxicodendron - 30C to 10M use chronically.
2.* Rhododendron - 6X to 15C.
3.* Elaterium - 15C especially gouty arthritis and arthritic nodules.
4. Arbutus andrachne - 3X to 15C better on larger joints.
5.* Bryonia alba tinct. - 12X to 15C especially with swelling, knees, feet.
6.**Apocynum androsaemifolium - 200X to 30C use when all joints hurt, swelling in feet, hot feet.

Treatment Schedule

Doses cited are to be administered on a 3X daily schedule, unless otherwise indicated. Dose usually continued for 2 weeks. Liquid preparations usually use 8-10 drops per dose. Solid preps are usually 3 pellets per dose. Children use 1/2 dose.

Legend

X = 1 to 10 dilution - weak (triturition)
C = 1 to 100 dilution - weak (potency)
M = 1 to 1 million dilution (very strong)
X or C underlined means it is most useful potency
Asterisk (*) = Primary remedy. Means most necessary remedy. There may be more than one remedy - if so, use all of them.

References

Boericke, D.E., 1988. Homeopathic Materia Medica.

Coulter, C.R., 1986. Portraits of Homeopathic Medicines.

Kent, J.T., 1989. Repertory of the Homeopathic Materia Medica.

Koehler, G., 1989. Handbook of Homeopathy.

Shingale, J.N., 1992. Bedside Prescriber.

Smith, Trevor, 1989. Homeopathic Medicine.

Ullman, Dana, 1991. The One Minute (or so) Healer.

Tissue Salts

Ferr. Phos.	early stages of rheumatism, pain, fever;
Kali Mur.	fibrositis (fibromyalgia), white-grey-coated tongue;
Kali Sulf	shifting pains,worse in heated room, or evening;
Nat. Sulf.	primary remedy in gout. Rheumatic pains associated with biliousness;

Herbal Approaches

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Herbs
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Burdock Root (Arctium lappa)
Cayenne (Capsicum annuum)
Celery Seed (Apium graveolens)
Chaparral (Larrea divaricata)
Curcumin (Turmeric)
Ginger
Kelp (Laminaria, Macrocystes, Ascophyllum)
Meadowsweet
Queen-of-the-Meadow Root (Eupatorium purpureum)
Sarsaparilla Root (Smilax aristolochi-aceafolia)
White willow bark
Wild yam

Note: The misdirected use of an herb can produce severely adverse effects, especially in combination with prescription drugs. This Herbal information is for educational purposes and is not intended as a replacement for medical advice.

Discussion:

Burdock Root is an effective blood purifier and pain killer (analgesic).

Cayenne is a leading rubefacient herb, stimulating local blood circulation when applied topically. It may also be taken internally although it is extremely hot and must be taken in small quantities by most people. Ginger, in the form of a poultice, is also used to bring warmth to an area.

Celery Seed is a powerful diuretic and blood purifier, often used in cases of gout. Dandelion and yarrow are also used to stimulate urine production, which removes toxins.

Kelp may be beneficial in arthritis in a number of ways, not all of them clearly elucidated. Besides being nutritive and antibiotic it increases resistance to fevers and infections.

The first thought, of course, is to reduce inflammation for which the following herbs are commonly used: Meadowsweet, White willow bark and Wild yam. Meadowsweet contains salicylic acid and methyl salicylate, although willow bark is the original source for salicin, the precursor to "aspirin". The herbal community feel that the synergy of materials in the raw bark is superior to the refined version and may enhance its well known analgesic, antipyretic, antiinflammatory and antiseptic properties.

Valerian and Chamomile are excellent relaxants and sedatives, which relives pain and allows the patient to be properly rested.

Wild yam extracts are noted for their role in hormonal balancing. Since a number of arthritic conditions have an autoimmune element, somehow linked more closely with the female gender, hormonal balance may play a role, especially in female auotimmune disorders like rheumatoid arthritis and lupus.

Sarsaparilla also has a hormonal component, although its main contribution may be its antimicrobial activity. It is used as a diuretic and against fevers. The homeopathic version is now used for multiple sclerosis.

With new (to Western markets) Ayurvedic and Traditional Chinese cures being marketed along with the more traditional European and American products, the patient now has an overwhelming number of choices available. Professional advice can help to find the best options.

Boswellin is a recent addition to our armamentarium, deriving from Ayurveda. It is a potent antiinflammatory. It is commonly combined with Curcumin (as in Indian curry). Unlike NSAIDs, they do not produce stomach distress. They naturally complement glucosamine sulfate in providing nutritional support for joints. They restore blood flow by restoring damaged blood vessels. Turmeric inhibits hyaluronidase activity, which, otherwise, can damage tissues and allow infection to set in.

Alfalfa (Medicago sativa) is being recommended for symptomatic arthritis. [Equal parts of the seed and leaf.] It does contain a wide range of nutrients, essential in bone formation. However, definitive research has not been done.

It may also be noteworthy that some practitioners warn that members of the nightshade family (solanaceae) may contribute to and exacerbate the symptoms of arthritis. This includes the potato and all its derivative products.

Fibromyalgia

Capsaicin has been recommended for this form of non-articular arthritis. It is used topically at a strength of 0.025%. It should be used sparingly in affected areas.

Besides warming the area, it may inhibit the neurotransmitter (designated as substance P for pain) responsible for neurogenic inflammation. Of course it is also irritating to the eyes and other mucosal surfaces, which should be avoided. (Most people will not make this mistake more than once!]

References:

Childers, NF: A relationship of arthritis to the solanaceae (nightshades). Int. J. Prev. Med. 1982 (Nov):31-37.

Hoffmann, D: The New Holistic Herbal. Element, 1983. Third edition 1990.

Walji, H: Arthritis: struggle with immobility. Natural Health Series. Kian Press, 1997.

Aromatherapy - Essential Oils

Some oils that are beneficial for osteoarthritis are contraindicated for rheumatoid arthritis, which is an auto-immune disease and some of the recommended oils actually stimulate the immune system.

Osteoarthritis:

Chamomile Essence,	Coriander Essence,
Cypress Essence,	Eucalyptus Essence,
Ginger Essence,	Juniper Essence,
Lavender Essence,	Lemon Essence,
Marjoram Essence,	Pine Essence,
Rosemary Essence.

Rheumatoid arthritis:

Coriander Essence,	Cypress Essence,
Ginger Essence,	Juniper Essence,
Lavender Essence,	Marjoram Essence,
Pine Essence.

Related Health Conditions

Acromegaly	Aging
Anemia	Anorexia
Bursitis	Diabetes Mellitus
Fatigue	Fever
Gout	Infection
Injury	Ochronosis
Osteoarthritis	Pain
Rheumatoid arthritis

Abstracts

References

Ayres, S. & R. Mihan. Is Vitamin E Involved in the Autoimmune Mechanism? Cutis, 21. 1978.

Berkow, R. 1977. The Merck Manual. Merck Sharp and Dohme Research Laboratories Pub., Rahway, New Jersey. 2165 pp.

Bland, Jeffrey. Medical Applications of Clinical Nutrition. New Canaan, Conn.: Keats, 1983.

Carmichael, H.A. 1982. Uses of nutritional precursors of Prostaglandin E1 in the management of Rheumatoid Arthritis & chronic Coxsackie infection. Clin Uses Of Essential Fatty Acids. D.F. Horrobin, ed. Eden Press Inc.

Chasroff, I.J. & J.W. Ellis. 1983. Family Medical Guide, William Morrow and Company Inc., Pub. 594 pp. The Arthritis Foundation. Home Care Programs In Arthritis. 1314 Spring St. NW, Atlanta, GA 30309, U.S.A.

Childers, N.F.: A relationship of arthritis to the solanaceae (nightshades). Int. J. Prev. Med. 1982 (Nov.): 31-37.

Denman, A.M. et al: Joint complaints and food allergic disorders. Ann. Allergy, 1983, 51: 260-263.

De Vos, M. : "Articular Diseases and The Gut: Evidence For a Strong Relationship Between Spondylarthropathy and Inflammation of The Gut in Man., ACTA Clinica Belgica, 1990;45(1):20-24.

Eagles, J.A. & M.N. Randall. 1980. Handbook of Normal and Therapeutic Nutrition. Raven Press, New York. 323 pp.

Ehret, Charles F. and Lynn Waller Scanlon. 1983. Overcoming Jet Lag. Berkley Books Pub., New York. p. 160.

Eisinger, J. & Ayavou, T.: Transketolase stimulation in fibromyalgia. J. Am. Coll. Nutr. 1990, 9(1): 56-57.

Ellis, J.M.: Vitamin B6 deficiency and rheumatism. Anabolism, 1985.

Golding, D.N.: "Is There an Allergic Synovitis?", Journal of The Royal Society of Medicine, May 1990;83:312-314.

Heinerman, John, Ph.D. 1982. Herbal Dynamics. Root of Life, Inc.: Publ.

Houston DK et al., Health and dietary characteristics of supplement users in an elderly population. Int J Vitam Nutr Res, 1997, 67:3, 183-91.

Ingelfinger, F.J. 1980. Dorlands Medical Dictionary. Saunders Press Pub., Philadelphia. 740 pp.

Jameson, S. et al: Pain relief and selenium balance in patients with connective tissue disease and osteoarthritis: a double-blind selenium tocopherol supplementation study. Nutr. Res. 1985, 1(Supp): 391-397.

Kirban, S. Medical Approach versus Nutritional Approach To Arthritis. Published by Oxford: Oxford Univ Press, 1983. pp. 12.70 - 12.80.

Kremer, J.M. Effects of Manipulation of Dietary Fatty Acids on Clinical Manifestations of Rheumatoid Arthritis. Lancet,(Jan 26, 1985).

Krupp, M.A. and Chatton, M.J. (Ed). Current Medicinal Diagnosis and Treatment. Lange Medical Publications, U.S.A., 1984. pp. 367-368.

Kuhnau, J. The Flavonoids: Role in Human Nutrition. World Review Of Nutrition And Dietetics, 24 (1976).

Kunz, J.R.M. 1982. The American Medical Association Family Medical Guide. Random House Pub, New York. 832 pp.

Mandell, M. & Conte, A.A.: The role of allergy in arthritis, rheumatism and polysymptomatic cerebral, visceral and somatic disorders: a double blind study. J. Int. Acad. Prev. Med. 1982 (July): 5-16.

Nizzi, S.K. 1987. The Omega 3 Connection. Esquire Books, Inc.

Panush, R. S. : "Food Induced ("Allergic") Arthritis: Clinical and Serological Studies." Journal of Rheumatology, 1990;17(3):291-294.

Pennington, J. 1978. Nutritional Diet Therapy. Bull Publishing Co., Palo Alto, Ca. 106 pp.

Petersdorf, R. G. & R. D. Adams. 1983. Harrison's Principles Of Internal Medicine. 10th ed. McGraw Hill Pub Co., New York. 2212 pp.

Ramsey, N. et al.: "Dietary Treatment of Rheumatoid Arthritis","The Practitioner", May 8, 1990;234:456-460.

Regtop, H. Dietary Antioxidants and Inflammatory Disease. Yearbook Of Nutritional Medicine: 1984. New Canaan, Conn.: 1985.

Rowe, A.H.: Allergic fatigue and toxemia. Ann. Allergy, 1959, 17: 9-18.

Seltzer, S., Marcus, R. & R. Stoch. Perspectives in the Control of Chronic Pain by Nutritional Manipulation. Pain, 11 1981.

Steinberg, C.L. : Vitamin E and collagen in rheumatic diseases. Ann. NY Ac. Sci. 1949, 52: 380-389.

Terano , T., et al. 1985. Eicosapentaenoic acid as a modulator of inflammation. Biochemical Pharmacology. 35: 779-785.

The editors of Prevention Magazine. The Complete Book of Vitamins. All New Edition, Emmaus, PA. Rodale Press. 1984. Chapter 13.

Thomas, C.L. 1985. Taber's Cyclopedic Medical Dictionary. F.A. Davis Co. Pub., Philadelphia. 2170 pp.

Travers, R. L. et al, "Boron and Arthritis: The Results of a Double-Blind Pilot Study", Journal of Nutritional Medicine, 1990;1:127-132.

Travers, Richard L "Clinical Trial - Boron on Arthritis." Townsend Letter For Doctors, June 1990;360-362.

Walji, Hasnain. 1994. Arthritis & Rheumatism - Orthodox & Complementary Approaches Hodder Headline Plc.London.

Walker, W.R. & Keats, D.M.: An investigation of the therapeutic value of the "copper bracelet": dermal assimilation of copper in arthritic/rheumatoid conditions. Agents Actions, 1976, 6: 454.

Whitehouse, M.W., et al: "Zinc Monoglycerolate: A Slow-Release Source of Zinc With Anti-Arthritic Activity in Rats", , Agents and Actions, 1990;31/47-58.

Wyngaarden, J.B. & L.H. Smith. 1985. Cecil's Textbook of Medicine. Saunders Pub Co., Philadelphia. 2341 pp.

Zeman F.J. 1983. Clinical Nutrition and Dietetics. The Collamore Press; Lexington, Mass. 682 pp.