I recently came across a study comparing glucosamine versus acetaminophen. Researchers from Madrid, Spain, compared the benefit of glucosamine sulfate versus acetaminophen (Tylenol) on the symptoms of knee osteoarthritis during a 6-month treatment course. Patients were randomly assigned to receive oral glucosamine sulfate 1,500 mg once daily, acetaminophen 3 gm a day, or placebo. There were more responders to glucosamine sulfate (39%) and acetaminophen (33%) than to placebo (21%). Safety was good, and was comparable among groups. The findings of this study indicate that glucosamine sulfate is more effective than placebo and more or as effective as acetaminophen in treating knee osteoarthritis symptoms.

Dr. Sahelian Comments: Acetaminophen works quicker to relieve pain, but can cause harm to the liver, even at doses of one gram a day. I do not think it is a good drug to be taken long term for a chronic condition such as osteoarthritis. There is a possibility that if glucosamine is combined with chondroitin and other nutrients or herbs it may be more beneficial than by itself. I wonder how many years it will take for the American Board of Family Medicine to include natural supplements as options in their multiple choice questions and answers.

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* Investigate food allergies. NSAIDs can make you more food-sensitive. Remove nightshades (potato, tomato, bell peppers, aubergine) from your diet.

* Increase your levels of antioxidants, particularly vitamin C, which is necessary for collagen synthesis. High levels can reduce the rate of cartilage loss by 70 per cent (Arthritis Rheum, 1996; 39: 648-56). Vitamin E (600 IU) can also help collagen breakdown in OA (J Am Geriatr Soc, 1978; 26: 328-30). Take both vitamins together.

* Take high doses of B vitamins, particularly niacinamide, or vitamin B3 (from 900 mg to 4 g, in divided doses), to increase movement in OA (J Am Geriatr Soc, 1955; 3: 927) – but only under medical supervision, as high levels can cause glucose intolerance and liver damage. Vitamin B12 and folic acid can help control pain (J Am Coll Nutr, 1994; 13: 351-6).

* Increase your levels of omega-3 fatty acids through fish, fish oils, omega-3 supplements and zinc.

* Supplement with Devil’s claw (Harpagophytum procumbens), which can increase mobility (J Appl Nutr, 1987; 27: 45-50).

* Take boron, also shown to help with bone and OA (J Nutr Med, 1990; 1: 127-32). Dr Melvyn Werbach suggests that, as the minimum daily allowance for boron is still not established, patients should increase their consumption of boron-rich foods (vegetables such as soya, cabbage, lettuce and peas; fruits such as apples, dates, raisins and prunes; nuts, especially almonds, hazelnuts and peanuts).

* Try supplementing with glucosamine, the chief component of proteoglycans, a major building-block of cartilage, to rebuild damaged cartilage (Orthop Praxis, 1970; 9: 225). Research shows that it helps reverse the disease (Int J Tissue React, 1992; 14: 243-51; Clin Ther, 1980; 3: 260-72).

Glucosamine is often taken with chondroitin sulphate, one of the main glycosaminoglycans found in cartilage,as the two often work in synergy. However, when using intermuscular chondroitin, be wary of kidney/liver toxicity (Lancet, 1989; i: 1275).

* New Zealand green-lipped mussel extract may help (Lancet, 1981; i: 439).

But the drugs can’t work if they’re injected into the wrong place. Doctors have been found to miss the correct injection site up to 25 per cent of the time – regardless of how experienced they are (J Bone Joint Surg Am, 2002; 84: 1522-7).

I have sought help from numerous consultants and general practitioners, but have been told that the coccyx is still a mystery. I have also seen two osteopaths in recent years, but both of them added to the pain, especially the second one, whom I consulted 15 months ago.

Apart from the unbearable pain, there is also a sensation of intense heat, like a red-hot poker in the rectum. Needless to say, my rectum has suffered as a result – and, apparently, nothing can be done about that either.

Acupuncture has not helped and painkillers do not reach the area. I am desperate – for years now, the pain has woken me up in the early hours of the morning so I get very little sleep.

I have never had the coccyx X-rayed or scanned, and I am wondering if this should be my next step. – E.M. Stacey, Bedford

A: Given the persistence and severity of your coccydynia (coccyx pain), it may be wise to go for a thorough examination, including imaging diagnostic tests such as X-rays or an MRI scan. This is to make sure that the pain is indeed coming from your coccyx, and not from something else in the area.

Several things can cause coccyx pain. It could arise from an unstable coccyx – one that moves about too much when you sit down – as a result of trauma such as a fall, childbirth or car accident, or from a weakening of the joint. It could also be due to: a misaligned coccyx; a rigid, non-flexible coccyx; a coccyx that is too long; the growth of bony spurs on the coccyx; or damaged nerves in the region. An X-ray or MRI scan will rule out an infection or tumour. Finally, there are cases, such as yours, where the pain follows medical treatment such as an epidural or back surgery.

As your pain followed a bad epidural, WDDTY panellist Dr Harald Gaier suggests that the needle may have damaged the cartilage between the various segments that make up the tailbone. And, in this case, manipulation would indeed do little to resolve the problem.

However, taking into account your experiencing of intense heat in the anal region, the problem may not lie with the coccyx, but with the neighbouring sacral area. The intense heat may be a referred sensation from the second sacral (S2) nerve. I would use a special traction method that involves the sacroiliac joints to alleviate the problem, says Dr Gaier.

The treatment for your coccydynia will depend on the cause. Unless you know what this is, it is difficult to advise you on what the appropriate treatment would be.

But, in the meantime, there are various pain-relief therapies besides acupuncture and osteopathy that you may wish to try to make your life more bearable.

* Massage is a recognized method of pain management that also helps to boost the immune system, and reduce anxiety and stress. It is believed that, by massaging the skin, messages are sent up the spine, stimulating the vagus nerve in the brain. Levels of the stress hormone cortisol are then lowered while those of the feel-good hormone serotonin are raised.

In a study comparing massage, acupuncture and self-care education for persistent back pain, massage proved superior to the two other therapies in reducing symptoms and disability. In addition, the massage group used the least medications and had the lowest costs of subsequent care (Arch Intern Med, 2001; 161: 1081-8). Massage therapy can also been ease fibromyalgia, and was more effective than relaxation therapy in helping people improve their sleep (J Clin Rheumatol, 2002; 8: 72-6).

* Magnetic therapy is better known for managing pain rather than curing it. The theory behind this therapy is that the magnetic fields produced by magnets (or devices that generate an electromagnetic current) can penetrate the body, and improve the functioning of individual cells, the nervous system and various organs.

In patients with knee pain due to chronic osteoarthritis, exposure to a low-frequency magnetic field for six minutes, in eight sessions, produced significant pain relief in 46 per cent of patients, compared with 8 per cent of those who received dummy magnetic therapy (Altern Ther Health Med, 2001; 7: 54-64, 66-9).

In yet another study, also involving patients with osteoarthritis, hip and knee pain were both reduced when the patients wore a standard-strength, static, bipolar magnetic bracelet for 12 weeks (BMJ, 2004; 329: 1450-4).

* Take 1-2 g/day of powdered ginger. Dubbed ‘nature’s aspirin’, as a potent antirheumatoid/anti-inflammatory, ginger is commonly used in traditional Chinese and Ayurvedic medicine to help patients with rheumatoid disorders (any painful condition of the joints/muscles/connective tissues).

* Boost your B vitamins. Vitamin B6 (pyridoxine) is essential for the manufacture of neurotransmitters such as serotonin, one of the body’s own painkillers. The recommended supplement dose is 50 mg once or twice a day. It is found in a wide variety of foods, including cereals, beans, meat, poultry, fish, bananas and vegetables – in particular, potatoes. Make sure you also have a sufficient intake of vitamin B2 (riboflavin), as it helps promote the uptake of vitamin B6 as well as other B vitamins. Foods rich in riboflavin include meat, cheese, egg yolk, yoghurt, milk and poultry. Other sources are green leafy vegetables, broccoli, soy products and enriched bread. It is recommended that riboflavin be taken with an equivalent amount of vitamin B6.

* Eat high-fibre foods and drink plenty of fluids. This will soften stools and avoid constipation. Consume plenty of fresh fruits and vegetables, cooked wholegrain cereals with added bran, and foods containing wholegrains such as amaranth, quinoa, oat bran and rye. Make sure that you drink 8-10 glasses of fluid every day. Tea and coffee can be effective laxatives but, as caffeine can contribute to constipation, it should not be included in your daily count of fluid intake.

Ten osteoarthritis patients who agreed to be treated with leeches – which sucked blood from around the arthritic knee for 80 minutes – enjoyed significant pain relief for 28 days afterwards (Ann Rheum Dis, 2001; 60: 986).

Maggots have also done their bit for patients whose wounds wouldn’t heal. Of 21 volunteers, 17 reported that the maggots completely or significantly cleared the wound. Of the four others, two died, one disappeared and the fourth kept walking on his foot ulcer, so squashing the maggots. Some who refused treatment were worried that the maggots might escape and, indeed, this did happen twice. But compared to adverse drug reactions, you might feel you’re still ahead of the game (Arch Phys Med Rehabil, 2001; 82: 1226-9).

Professor P A Dieppe and other researchers from the University of Bristol, reviewing clinical trials of paracetamol and NSAIDs for OA to date concluded that paracetamol reduced pain and tenderness significantly. None of the literature supports the widespread assertion that NSAIDs are better at reducing pain and joint stiffness than paracetamol alone.

The Bristol researchers furthermore said that the entire approach to osteoarthritis, which strikes one in eight people over 65, has been “misdirected” by concentrating on the role of NSAIDs. These drugs primarily reduce inflammation as well as pain, whereas OA causes only minor inflammation, which doesn’t really account for most of the pain of the disease.

“The models adopted to develop NSAIDs are irrelevant to osteoarthritis, but patients with this disorder are now the main recipients of these drugs,” they said. In one study, more than three quarters of frequently prescribed NSAIDs were given for OA.

They also dispute the conclusions of the hundreds of papers on NSAIDs now published. Most of the studies showing pain relief from NSAIDs were conducted over a few weeks, whereas the pain of osteoarthritis can be present for months or years in most cases. Furthermore, the studies tend to compare different NSAID agents against each other, showing little difference. The researchers were mystified to discover that there are virtually no studies comparing the NSAIDs with the simple analgesics.

“Given the huge number of studies of NSAIDs in osteoarthritis, it is tempting to conclude that one of the main reasons for this paucity of comparative studies. . . must be the vested interests of the pharmaceutical industry,” they said.

Professor Dieppe and his cohorts said that simple painkillers have many advantages over NSAIDs. Besides being cheaper, they do not have the toxic effects of NSAIDs, particularly gastrointestinal damage, which is highest in elderly women, the very group in which OA is most prevalent. “Many patients with osteoarthritis could be managed as well or better with simple analgesics and rubefacients [which cause warming of the skin] than with NSAIDs, they said.

The American College of Rheumatology had recommended that exercises be one of the mainstays of treatment, but doctors have been unclear about the type of exercise to recommend, or its duration.

Researchers from the Fitness Arthritis and Seniors Trial (FAST) tested the recommendation out on 365 sufferers who completed the 18 month trial. Those in the aerobic team walked in their neighbourhood as part of a programme that consisted of 10 minutes of warm up, 40 minutes of walking and then a final cool down period of 10 minutes, three times a week.

The second programme of resistance exercises followed a similar pattern but involved nine exercises to improve overall muscle fitness.

The researchers said that “modest” improvements were reported, although those who did more of the exercises reported greater benefits (JAMA, 1997; 277: 25-31).

Moderate exercise can also help people sleep better, researchers have found. Healthy, but sedentary, older people who had sleeping problems found they had a better night’s sleep if they did some exercise.

The programme consisted of 30 minutes of low impact aerobics or brisk walking four times a week, report researchers from Stanford University (JAMA, 1997; 277: 32-7).

This was the finding of a three year randomised placebo controlled European trial, involving 212 patients with osteoarthritis of the knee. Patients were randomly assigned to receive either 1500 mg of oral glucosamine sulphate or placebo, once daily, for three years. Benefit was assessed by weightbearing X-rays of each knee, taken after one year and at the end of the study. All patients in the placebo group showed joint deterioration whereas those taking glucosamine did not. Placebo patients also reported a worsening of symptoms while those taking the supplement reported improvement (Lancet, 2001; 357: 251-6).

This study is something of a breakthrough for pundits of nutritional supplements. An accompanying commentary suggests that glucosamine could represent a new era not just in the treatment of osteoarthritis, but also when doctors must begin to “accommodate the possibility that many nutritional products may have valuable therapeutic effects” (Lancet, 2001; 357: 247).

The researchers measured knee joint rotation in 20 women who alternatively walked barefoot or in one of two pairs of their own shoes of comparable heel heights.

The average heel height was 7.0 cm. The narrow base shoes were an average of 1.2 cm wide while the wide base shoes averaged 4.5 cm wide.

It was found that increasing the width of a shoe’s heel did nothing to improve the abnormal gait caused by wearing high heels, and that wearing wide heeled shoes had a 30 per cent greater adverse effect on knee rotation than walking barefoot.

The doctors also noted that women who opt for wide heels are putting increased pressure on the surrounding tendons and joints. Even more than thin heeled shoes, wide heels raised the risk of such degenerative changes in the knee as osteoarthritis (Lancet, 2001; 357: 1097-8).