Boswellia: A PT Game-Changer in Managing Knee Arthritis?

Boswellia: A PT Game-Changer in Managing Knee Arthritis?

By Dr. Sean M. Wells, PT, DPT, OCS, ATC/L, CSCS, CNPT, Cert-DN

In the quest for alternative and effective treatments for knee osteoarthritis (OA), a degenerative joint condition marked by pain, swelling, and diminished mobility, Boswellia serrata, commonly known as Indian frankincense, is emerging as a promising solution. Many of my physical therapy patients have asked about Boswellia, and honestly it was never covered in PT school so the depth of my answer was limited. Fortunately with my continued education, writing textbooks, and research advancements, Boswellia appears to be a possible solution for helping our PT clients with arthritis. Let's understand what it is, how it works, and if it is something you should discuss with your clients.

Tackling Inflammation at its Core
With its potent anti-inflammatory properties, Boswellia has shown remarkable potential in subduing the chronic inflammation associated with knee osteoarthritis. Active compounds such as boswellic acids are believed to block the production of pro-inflammatory enzymes, providing much-needed relief to swollen and painful joints. Some of these enzymes include:

• Inhibition of 5-Lipoxygenase (5-LOX): Boswellic acid is well-known for its ability to inhibit the 5-lipoxygenase enzyme, which plays a critical role in the biosynthesis of leukotrienes. Leukotrienes are inflammatory mediators derived from arachidonic acid that contribute to inflammatory and allergic responses. By inhibiting 5-LOX, boswellic acid reduces the production of leukotrienes, which can help to alleviate inflammation.
• Inhibition of NF-κB Activation: Nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) is a transcription factor that plays a central role in regulating the expression of genes involved in inflammation, immune response, and cell survival. Boswellic acid has been shown to inhibit the activation of NF-κB, which can lead to a reduction in the expression of pro-inflammatory genes.
• To a lesser degree boswellic acid reduces COX-1 and COX-2, which is routinely suppressed by non-steroidal anti-inflammatorys (NSAIDs). It also has a small impact on reducing certain cytokines that can produce inflammation.

It would appear that Boswellia has several pathways that can potentiate reducing inflammation for those with arthritis. With several pathways to reduce inflammation, it is not supprising that boswellia helps to relieve pain in those with OA.

A Natural Painkiller
Patients battling knee osteoarthritis have reported significant pain reduction and enhanced joint flexibility with the use of Boswellia. According to a 2020 systematic review and meta analysis, when taken for 4 weeks and compared to a control group, Boswellia did relieve pain significantly [VAS: (WMD -8.33; 95% CI -11.19, - 5.46; P<0.00001). A weighted mean difference (WMD) of -8.3 would be considered a large effect, and likely have a significant impact on clinical outcomes. This natural herb is proving to be a formidable ally in improving patients' quality of life, enabling them to navigate daily activities with greater ease, but what about it's ability to improve patient mobility and joint function?

Functioning
Individuals taking Boswellia can improve their knee stiffness, moblity, and functioning. Several studies have cited the improvements in the WOMAC scores, with this double blind, randomized, placebo controlled study finding nearly a 20 point reduction in the WOMAC score when taking 250mg of Boswellia for 90 days. A 20 point reduction would exceed the minimal clinidcal important difference (MCID) for the WOMAC. Now, imagine these subject had both Boswellia and physical therapy? Here's the graph from the study:

Another double blind, randomized, placebo controlled clinical study examined the efficacy of a trademarked type of Boswellia known as Aflapin. The study found similliar findings to the above RCT, citing improvements in pain, WOMAC scores, and alos the improvements in the Lequesne's Functional Index. Examining the data points, all the measures exceeded MCIDs for functioning, which meant people were walking, climbing stairs, transferring, and doing household chores with greater ease. While all of these data points sound great, how do they compare to NSAIDs and is Boswellia safe?

Gentle on the Body
One of the standout features of Boswellia is its safety profile. Unlike NSAIDs, which are commonly prescribed for osteoarthritis but come with a host of gastrointestinal side effects, Boswellia offers a gentler alternative. Its good tolerability makes it a viable option for long-term use, though a proper medical history and review of systems is paramount before embarking on this natural remedy. ome reports of gastrointestinal effects including abdominal pain, diarrhea, nausea and acid reflux. There are also rare reports of itchy skin and dermatitis. However, studies generally haven’t shown an increase in adverse events relative to control according to Yu et al. Interestingly the effects of Boswellia seem to begin at about 5 days and really peak around 4 weeks. One study found that those taking Boswellia vs NSAIDs still maintained benefits after one month of stopping -- this may be due to Boswellia's ability to alter joint cartilage as well. As such, should PTs treating patients with knee OA talk about Boswellia instead of the traditional ibuprofen? Perhaps... and this may be due to its ability to help joint cartilage. 

An Antioxidant Powerhouse and  A Ray of Hope for Cartilage
Boswellia’s antioxidant properties offer an additional layer of protection to the knee joint, combating oxidative stress and potentially decelerating the progression of osteoarthritis. This herb is not just about managing symptoms; it’s about supporting overall joint health. Preliminary studies suggest that Boswellia might play a role in preserving cartilage integrity, offering a beacon of hope for those seeking to maintain joint health and functionality. The Sangupta 2008 article showed a significant reduction in synovial fluid matrix metalloproteinase-3, which is involved in cartilage breakdown. Other similar lipoxygenase compounds have been linked with other cellular mediated changes that can support joints. This might explain the residual effect that Boswellia exerts after stopping the supplement. Regardless, more studies are needed to understand its role in joint destruction.

The Verdict
The journey to fully understanding and harnessing the benefits of Boswellia for knee osteoarthritis is ongoing, with more research needed to solidify its place in osteoarthritis management. What is clear, however, is that this ancient herb is making a modern-day comeback, providing a natural and promising option for our PT patients navigating the challenges of knee osteoarthritis. I will trial these herb with a select few of my clients with OA and see how they perform: will you do the same? Obviously, it is important for DPTs and patients to know their limits with supplements and herbs. Having the proper nutrition training, performing a thorough exam, following State practice acts, and conferring with other providers (MDs) is crucial to ensuring patient success and safety. Some additional information on dosing can be found here on Examine.com. Be well!

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Photo by Towfiqu barbhuiya: https://www.pexels.com/photo/person-holding-their-knee-11969599/

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