ArticlePDF Available

Effectiveness of collagen supplementation on pain scores in healthy individuals with self-reported knee pain; A randomized controlled trial

Authors:

Abstract and Figures

The purpose of this study was to examine the effects of 12 weeks collagen peptide (CP) supplementation on knee pain and function in individuals with self-reported knee pain. Healthy physically active individuals (n = 167; aged 63 [interquartile range = 56–68] years) with self-reported knee pain received 10 g/day of CP or placebo for 12 weeks. Knee pain and function were measured with the Visual Analog Scale (VAS), the Lysholm questionnaire, and the Knee injury and Osteoarthritis Outcome Score (KOOS). Furthermore, we assessed changes in inflammatory, cartilage, and bone (bio)markers. Measurements were conducted at baseline and after 12 weeks of supplementation. Baseline VAS did not differ between CP and placebo (4.7 [2.5–6.1] vs. 4.7 [2.8–6.2], p = 0.50), whereas a similar decrease in VAS was observed after supplementation (−1.6 ± 2.4 vs. −1.9 ± 2.6, p = 0.42). The KOOS and Lysholm scores increased after supplementation in both groups (p values < 0.001), whereas the increase in the KOOS and Lysholm scores did not differ between groups (p = 0.28 and p = 0.76, respectively). Furthermore, CP did not impact inflammatory, cartilage, and bone (bio)markers (p values > 0.05). A reduced knee pain and improved knee function were observed following supplementation, but changes were similar between groups. This suggests that CP supplementation over a 12-week period does not reduce knee pain in healthy, active, middle-aged to elderly individuals. Novelty CP supplementation over a 12-week period does not reduce knee pain in healthy, active, middle-aged to elderly individuals. CP supplementation over a 12-week period does not impact on inflammatory, cartilage, and bone (bio)markers in healthy, active, middle-aged to elderly individuals.
Content may be subject to copyright.
ARTICLE
Effectiveness of collagen supplementation on pain scores in
healthy individuals with self-reported knee pain: a randomized
controlled trial
Coen C.W.G. Bongers, Dominique S.M. Ten Haaf, Milène Catoire, Bregina Kersten, Jeroen A. Wouters,
Thijs M.H. Eijsvogels, and Maria T.E. Hopman
Abstract: The purpose of this study was to examine the effects of 12 weeks collagen peptide (CP) supplementation on knee pain
and function in individuals with self-reported knee pain. Healthy physically active individuals (n= 167; aged 63 [interquartile
range = 56–68] years) with self-reported knee pain received 10 g/day of CP or placebo for 12 weeks. Knee pain and function were
measured with the Visual Analog Scale (VAS), the Lysholm questionnaire, and the Knee injury and Osteoarthritis Outcome Score
(KOOS). Furthermore, we assessed changes in inflammatory, cartilage, and bone (bio)markers. Measurements were conducted at
baseline and after 12 weeks of supplementation. Baseline VAS did not differ between CP and placebo (4.7 [2.5– 6.1] vs. 4.7 [2.8–6.2],
p= 0.50), whereas a similar decrease in VAS was observed after supplementation (−1.6 ± 2.4 vs. −1.9 ± 2.6, p= 0.42). The KOOS and
Lysholm scores increased after supplementation in both groups (pvalues < 0.001), whereas the increase in the KOOS and Lysholm
scores did not differ between groups (p= 0.28 and p= 0.76, respectively). Furthermore, CP did not impact inflammatory, cartilage,
and bone (bio)markers (pvalues > 0.05). A reduced knee pain and improved knee function were observed following supplemen-
tation, but changes were similar between groups. This suggests that CP supplementation over a 12-week period does not reduce
knee pain in healthy, active, middle-aged to elderly individuals.
Novelty
CP supplementation over a 12-week period does not reduce knee pain in healthy, active, middle-aged to elderly individuals.
CP supplementation over a 12-week period does not impact on inflammatory, cartilage, and bone (bio)markers in healthy,
active, middle-aged to elderly individuals.
Key words: knee discomfort, collagen hydrolysate, cartilage, collagen synthesis, Lysholm questionnaire, KOOS questionnaire,
inflammation, bone biomarkers.
Résumé : Le but de cette étude est d’examiner les effets de 12 semaines de supplémentation en peptide de collagène (« CP ») sur
la douleur et la fonction du genou chez les personnes souffrant de douleur autodéclarée au genou. Les individus (n= 167) en
bonne santé et physiquement actifs (63 [écart interquartile = 56–68] ans) présentant une douleur autodéclarée au genou
reçoivent pendant 12 semaines 10 g/jour de CP ou un placebo. La douleur et la fonction du genou sont mesurées avec l’échelle
visuelle analogique (« VAS »), les questionnaires de Lysholm et de KOOS (Knee injury and Osteoarthritis Outcome Score). De plus, nous
évaluons les changements des (bio)marqueurs inflammatoires, cartilagineux et osseux. Les mesures sont effectuées au départ et
après 12 semaines de supplémentation. Le score VAS initial ne diffère pas entre le CP et le placebo (4,7 [2,5–6,1] vs 4,7 [2,8–6,2],
p= 0,50); toutefois, on note une diminution similaire du score VAS après la supplémentation (−1,6 ± 2,4 vs −1,9 ± 2,6, p= 0,42). Les
scores KOOS et Lysholm augmentent après la supplémentation dans les deux groupes (valeurs p< 0,001), mais l’augmentation
des scores KOOS et Lysholm ne diffère pas entre les groupes (p= 0,28 et p= 0,76, respectivement). De plus, le CP n’a pas d’impact
sur les (bio)marqueurs inflammatoires, cartilagineux et osseux (valeurs de p> 0,05). Une réduction de la douleur au genou et une
amélioration de la fonction du genou sont observées après la supplémentation, mais les changements sont similaires dans les
deux groupes. Ces résultats suggèrent que la supplémentation en CP sur une période de 12 semaines ne réduit pas la douleur au
genou chez les personnes d’âge moyen en bonne santé et les personnes âgées. [Traduit par la Rédaction]
Les nouveautés
La supplémentation en CP sur une période de 12 semaines ne réduit pas la douleur au genou chez les personnes d’âge moyen
et plus âgées, actives et en bonne santé.
Received 9 September 2019. Accepted 21 January 2020.
C.C.W.G. Bongers, D.S.M. Ten Haaf, B. Kersten, T.M.H. Eijsvogels, and M.T.E. Hopman. Radboud Institute for Health Sciences, Department of
Physiology, Radboud University Medical Center, Nijmegen 6500HB, the Netherlands.
M. Catoire. Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen 6500HB, the Netherlands;
TNO, Expertise Group for Training and Performance Innovations, Soesterberg 3769ZG, the Netherlands.
J.A. Wouters. Sports Centre Papendal/Eat2Move, Arnhem 6816VD, the Netherlands.
Corresponding author: Thijs M.H. Eijsvogels (email: Thijs.Eijsvogels@radboudumc.nl).
Copyright remains with the author(s) or their institution(s). Permission for reuse (free in most cases) can be obtained from copyright.com.
Pagination not final (cite DOI) / Pagination provisoire (citer le DOI)
1
Appl. Physiol. Nutr. Metab. 00: 1–8 (0000) dx.doi.org/10.1139/apnm-2019-0654 Published at www.nrcresearchpress.com/apnm on 28 January 2020.
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by RADBOUD UNIVERSITEIT NIJMEGEN on 06/25/20
For personal use only.
La supplémentation en CP sur une période de 12 semaines n’a pas d’impact sur les (bio)marqueurs inflammatoires, carti-
lagineux et osseux chez les personnes d’âge moyen et plus âgées, actives et en bonne santé.
Mots-clés : malaise au genou, hydrolysat de collagène, cartilage, synthèse de collagène, questionnaire de Lysholm, questionnaire
de KOOS, inflammation, biomarqueurs osseux.
Introduction
Articular cartilage is important for the transmission of loads
and to provide a smooth surface for low-friction joint movement
(DuRaine et al. 2009;Sophia Fox et al. 2009). Lubrication of the
cartilage surfaces is essential for a normal joint function (DuRaine
et al. 2009). In individuals with articular cartilage degradation, the
catabolic degradation exceeds the anabolic regeneration of artic-
ular cartilage by the chondrocytes (Goldring and Berenbaum 2004;
Goldring and Goldring 2004;Mueller and Tuan 2011). This results in
a limited ability for low-friction movements and consequently in the
development of knee joint pain and discomfort.
In 2000, Moskowitz was one of the first to describe the potential
beneficial effects of collagen peptides (CPs), also known as colla-
gen hydrolysate, as a treatment for osteoarthritis and osteoporo-
sis (Moskowitz 2000). Subsequently, a study by Oesser and Seifert
was the first demonstrating that CPs are able to stimulate the
biosynthesis of the extracellular matrix (ECM) of cartilage (Oesser
and Seifert 2003), but this finding was not confirmed in preclinical
studies (Schadow et al. 2013,2017). Proteoglycans are the principal
components of the ECM of articular cartilage and are critical for
low-friction joint movements and the prevention of knee discomfort
(Cohen et al. 1998;Iozzo and Murdoch 1996;Iozzo and Schaefer 2015;
Sophia Fox et al. 2009). Interestingly, changes in proteoglycan con-
tent in knee cartilage have been found using magnetic resonance
imaging measures among individuals taking CP supplements for
24 weeks (McAlindon et al. 2011). The use of CP supplements is
therefore considered as a beneficial strategy to reduce knee pain
and discomfort in patients with articular cartilage degradation
(Clark et al. 2008;Zdzieblik et al. 2016). Furthermore, it has been
suggested that various CP supplements differ in composition of
collagen fragments and, therefore, differ in pharmacological effi-
cacy on human synovial fibroblasts and cartilage (Schadow et al.
2013,2017;Simons et al. 2018). In those studies, undigested CP was
used in cell culture assays to determine its pharmacological effi-
cacy, which is different from a physiological situation in which
CP is modified during gastrointestinal passage by digestion en-
zymes and absorption processes (Sato 2017). Therefore, the use of
digested CP supplements in cell culture assay studies is warranted
to confirm the pharmacological efficacy of different CP supple-
ments.
To our knowledge the effects of CP supplementation have only
been examined in young athletes (Clark et al. 2008) or in patients
with diagnosed osteoarthritis (Kumar et al. 2015;Lugo et al. 2016).
Therefore, the aim of this study was to determine the effects of
12 weeks of CP supplementation on knee pain and knee function
in healthy, active, middle-aged to elderly individuals with self-
reported knee pain. Second, we examined the effects of CP sup-
plementation on changes in inflammatory, cartilage, and bone
(bio)markers. We hypothesized that 12 weeks of CP supplementa-
tion will reduce knee pain and improve knee function among
active elderly. Furthermore, we expected a decrease in inflamma-
tory, cartilage, and bone (bio)markers after 12 weeks of CP supple-
mentation.
Materials and methods
Participants
Participants were recruited between 22 March and 8 April 2016.
A total of 200 physically active participants (85 females and
115 males), aged between 50 and 75 years, volunteered to partici-
pate. All participants were in preparation for a multiple-day pro-
longed walking event (Four Days Marches, www.4daagse.nl) and
walked 30 km/week during the intervention period. Included
participants had a self-reported knee pain score in daily life > 1,
which was measured with the 100 mm Visual Analog Scale (VAS)
(Hawker et al. 2011). Participants were excluded based on the follow-
ing criteria: (i) systemic joint or muscle disease (i.e., rheumatoid
arthritis), (ii) diabetes mellitus type 1 or 2, (iii) disease influencing
the uptake of proteins (i.e., inflammatory bowel disease, Crohn’s
disease), (iv) recent knee surgery (<6 months), (v) statin usage, and
(vi) use of dietary supplements for joint health (i.e., gluco-
samine or chondroitin). All participants gave written informed
consent. The study was approved by a Medical Ethics Commit-
tee (NL56165.072.15), registered at a clinical trial register (Dutch
Trial Register; NTR5825), and performed in accordance with the
Declaration of Helsinki. Patients and the public were not involved
in this study.
Study design
In this double-blind, placebo-controlled trial, participants were
randomly allocated to either the intervention or placebo groups.
An independent representative randomized the study partici-
pants by means of computer-generated random numbers with a
block size of 10 in a 1:1 ratio. First, potential participants were
screened by phone to check for eligibility to participate (inclusion
and exclusion criteria, and knee pain score using the categorical
Numeric Pain Rating Scale (NPRS; 0–10)). Eligible participants
were invited for 2 study visits (baseline and after 12 weeks of
supplementation). At baseline, anthropometric data were mea-
sured and participants completed knee pain (VAS and Knee injury
and Osteoarthritis Outcome Score (KOOS)) and knee function (Lysh-
olm) questionnaires. A venous blood sample was taken to assess
inflammatory, cartilage, and bone (bio)markers. Subsequently, par-
ticipants started with the daily intake of the CP or placebo supple-
ment for 12 weeks. Participants had to complete a compliance
questionnaire every week. After 12 weeks of supplementation the
questionnaires were repeated and a venous blood sample was taken
again.
Intervention
Participants were randomly assigned to either a CP group (n= 100)
that received a CP supplement (Peptan B2000, Rousselot, Gent,
Belgium, molecular weight 2000 Da) for 10 g per day that was
derived from bovine hide (hydrolyzed collagen; proline/hydroxy-
proline (23%), glycine (21%), glutamic acid (12%), arginine (8%), ala-
nine (8%), essential amino acids (16%), and other amino acids (12%))
or a placebo group (n= 100) that received 10 g of maltodextrin on
a daily basis. Peptan B2000 has proven efficacy to support joint
health in both mice (Dar et al. 2017) and humans (Jiang et al. 2014),
respectively, while in both studies a different Peptan B2000 batch
was used. Moreover, participants in our study used CP supple-
ments from a single batch. The supplement had to be dissolved in
100 mL of water and consumed for 12 weeks in combination with
their habitual breakfast. The CP and placebo supplement were
indistinguishable from each other in terms of color, taste, and
viscosity. The research team was blinded for the randomization
order and an independent representative was the only person able
to break the randomization code.
Anthropometric measurements
Height and weight (Seca 888 scale, Hamburg, Germany) were
measured and used to calculate the body mass index (BMI). Body
Pagination not final (cite DOI) / Pagination provisoire (citer le DOI)
2 Appl. Physiol. Nutr. Metab. Vol. 00, 0000
Published by NRC Research Press
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by RADBOUD UNIVERSITEIT NIJMEGEN on 06/25/20
For personal use only.
fat percentage was calculated using a 4-point (biceps, triceps, sub-
scapular, and sub-iliac) skinfold thickness measurement (Durnin
and Womersley 1974). Furthermore, all participants completed
the short questionnaire to assess health enhancing physical activ-
ity to determine their habitual physical activity level (Nicolaou
et al. 2016). Handgrip strength of the dominant hand was mea-
sured using a hydraulic analogue hand dynamometer (Jamar,
Jackson, Mich., USA). Participants were seated with their elbow
flexed in a 90° angle position, and the dynamometer was adjusted
to their individual hand size. Three measurements were per-
formed, with 30 s of rest in between. Maximum strength in kilo-
grams was used for analysis.
Knee pain and function questionnaires
The primary outcome of this study was the VAS, which is a
widely accepted method for determining knee pain (Haefeli and
Elfering 2006;Hawker et al. 2011). The VAS consists of a horizontal
line of 100 mm in length, which is anchored by “no pain” (score of
0 mm) and “worst imaginable pain” (score of 100 mm) (Hawker
et al. 2011). Participants were instructed to draw a vertical line on
the VAS to indicate their level of knee pain. The Lysholm ques-
tionnaire was used to evaluate knee function based on instability,
swelling, locking symptoms, pain, need for support, possibility of
squatting and stair climbing, and the level of limb walking (Briggs
et al. 2009). The cumulative Lysholm score was calculated and
interpreted according the following knee function categories:
<65, poor; 65–83, fair; 84–90, good; and 91–100, excellent (Briggs
et al. 2009). The KOOS is a patient-reported outcome measure
intended for elderly adults with knee injury and/or knee osteoar-
thritis, and can be used to monitor disease following pharmaco-
logical and other interventions (Collins et al. 2016;Roos et al.
1998). The KOOS questionnaire holds 5 subscales: symptoms, stiff-
ness, pain, function in daily life, function in sports, and quality of
life (Collins et al. 2016). Each subscale is scored separately from 0
(extreme knee problems) to 100 (no knee problems), and a total
KOOS can be calculated based on the 5 subscales. The assessment
of VAS, Lysholm, and KOOS were performed at baseline and after
12 weeks of supplementation. Furthermore, participants were in-
structed to score their level of knee pain on weekly basis using the
NPRS (Hawker et al. 2011), a digitalized alternative of the VAS.
Cytokines and biomarkers
Nonfasted venous blood was drawn from the antecubital vein
before and after the 12 weeks supplementation period, and serum
samples were centrifuged (1200g/3000 rpm) and stored at −80 °C
until analysis. Serum interleukin 6 (IL-6), tumor necrosis factor
alpha (TNF-), monocyte chemoattractant protein-1 (MCP-1), and
C-reactive protein (CRP) were measured with the MSD multi-spot
assay system (MSD; Meso Scale Discovery, Rockville, Md., USA) to
examine inflammatory state (Pearle et al. 2007;Scheller et al. 2011;
Villiger et al. 1992;Wojdasiewicz et al. 2014). In addition,
C-terminal cross-linked telopeptide type II collagen (CTX-II) and
procollagen II C-terminal propeptide (P2CP) were measured using
an enzyme-linked immunosorbent assay (ELISA) (Hu CTX-II &
Fig. 1. Flowchart with overview of study participants. VAS, Visual Analog Scale.
Pagination not final (cite DOI) / Pagination provisoire (citer le DOI)
Bongers et al. 3
Published by NRC Research Press
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by RADBOUD UNIVERSITEIT NIJMEGEN on 06/25/20
For personal use only.
PIICP kit, Cloud-Clone Corp, China) and represented cartilage break-
down and cartilage formation, respectively (Conrozier et al. 2008;Fraser
et al. 2003;Rotterud et al. 2014). Furthermore, Carboxy-terminal telo-
peptides (CTX) and procollagen I intact N-terminal (PINP) were mea-
sured with an electro-chemiluminescence immunoassay (ECLIA)
(-crosslaps & total PINP, Roche Diagnostics International Ltd,
Switzerland) and represented bone resorption and bone formation,
respectively (Luftner et al. 2005;Lumachi et al. 2013). Analysis were
performed by trained technicians using standard operating proce-
dures on a single day using the same calibration and set-up to mini-
mize variation.
Statistical analysis
A per protocol analysis was used including only the participants
that completed all study procedures for the primary outcome.
Statistical analysis was performed using SPSS (version 25; IBM
SPSS, Armonk, N.Y., USA), in which the level of significance was set
at p< 0.05. Normality of the data was examined using a Shapiro–
Wilk test. Normally distributed data were reported as means ± stan-
dard deviation, whereas non-Gaussian distributed data were
presented as median [interquartile range (IQR)] and tested with
nonparametric equivalent statistical tests. Furthermore, data
were presented with 95% confidence intervals (CI) as well. A
2
test
was used to examine differences in sex distribution between
groups. An independent Student’s ttest or a Mann–Whitney Utest
was used to examine differences in participant characteristics
between groups. Supplement compliance was calculated as a per-
centage of the number of supplements taken divided by the total
number of available supplements during the study. Because the
majority of data was non-Gaussian distributed, we used a paired
Student’s ttest or a Wilcoxon signed-rank test to assess differ-
ences in baseline characteristics and knee outcome parameters
(VAS, KOOS, and Lysholm) between baseline and week 12 in both
groups. Subsequently, we calculated differences () in knee pain,
knee function, inflammatory markers, and bone and cartilage
biomarkers between baseline and week 12, and used an indepen-
dent Student’s ttest or a Mann–Whitney Utest to assess differ-
ences between the CP versus placebo groups. Linear mixed model
analysis was used to determine whether time-dependent changes
in knee pain (NPRS) differed between groups during the supple-
mentation period. A post hoc Bonferroni correction was applied
to correct for multiple comparisons.
Results
Participants
Although all participants scored their level of knee pain >1 upon
study enrollment (NPRS during telephone screening), a total of
16 participants (CP: n= 12; placebo: n= 4) reported a VAS < 1 at
baseline and were, therefore, excluded from further analysis. Fur-
thermore, 17 participants dropped-out during the supplementa-
tion period, resulting in a total of 167 participants (CP: n= 77;
placebo: n= 90) available for statistical analyses (Fig. 1). Supple-
ment intake difficulties (gastrointestinal complaints, intake difficul-
ties, or a smelly breath) were reported in 3 participants, while no
other adverse events were reported. Participants in the CP group
were significantly older compared with the placebo group (65 [IQR =
58–68, 95% CI = 62–65] years versus 61 [IQR = 55 –67, 95% CI = 60 –63]
years, p= 0.036). Sex, BMI, and physical activity characteristics did
not differ between groups (all pvalues > 0.05, Table 1). Supple-
ment compliance was high and did not differ between groups
(CP = 99.6% ± 1.2%, 95% CI = 99.3–99.9 vs. placebo = 99.4% ± 1.5%,
95% CI = 99.1–99.7, p= 0.29).
Knee pain and function
VAS
Baseline VAS was 4.7 [IQR = 2.5–6.1, 95% CI = 3.9– 4.9] for the CP
group and 4.7 [IQR = 2.8–6.2, 95% CI = 4.2–5.0] for the placebo
group, and did not differ between groups (p= 0.50, Fig. 2). We
found a decrease in VAS in both groups after 12 weeks of supple-
mentation (both p< 0.001), while the magnitude of the decrease
(CP = −1.6 ± 2.4, 95% CI = −2.1 to −1.1; Placebo = −1.9 ± 2.6, 95% CI =
−2.5 to −1.4) did not differ between groups (p= 0.42). Similarly, a
gradual decline in NPRS scores was found during 12 weeks of
follow-up (p< 0.001), but the decline did not differ between groups
(p= 0.20, Supplemental Fig. S1
1
).
KOOS
Baseline KOOS score did not differ between the CP (302 ± 68,
95% CI = 287–317) and placebo groups (308 ± 64, 95% CI = 294–322,
p= 0.55, Fig. 3A). An increased total KOOS score was found after
12 weeks of supplementation in both groups (CP=41±56,
95% CI = 29–54; Placebo = 31 ± 68, 95% CI = 16– 45, both p< 0.001),
whereas the increase did not differ between groups (p= 0.28).
Lysholm
We found a comparable baseline Lysholm score in the CP group
(IQR = 66 [56–71, 95% CI = 61–67]) and the placebo group (68 [IQR =
60–76, 95% CI = 65–70], p= 0.07, Fig. 3B). Both groups demonstrated
an increased Lysholm score after 12 weeks of supplementation
(both p≤ 0.001), whereas the increase did not differ between
groups (CP = 5 [IQR = −2 to 14, 95% CI = 3–8] and Placebo = 5 [IQR =
−3 to 16, 95% CI = 3–9], p= 0.76).
Blood markers
Inflammatory markers
No baseline differences in serum IL-6, TNF-, MCP1, and CRP
were found between groups (p= 0.86, p= 0.28, p= 0.55, p= 0.80,
respectively). Moreover, no changes in inflammatory markers
1
Supplementary data are available with the article through the journal Web site at http://nrcresearchpress.com/doi/suppl/10.1139/apnm-2019-0654.
Table 1. Participant characteristics.
All (n= 167) CP (n= 77) Placebo (n= 90) p
Sex (male/female) 99/68 49/28 50/40 0.29
Age (y)* 63 [56–68] 65 [58–68] 61 [55–67] 0.036
Height (cm)* 173 [166–181] 174 [166–180] 173 [165–182] 0.85
Body mass (kg) 80.5±12.9 79.8±12.3 81.2±13.5 0.48
BMI (kg/m
2
)* 26.4 [24.2–28.9] 26.4 [24.1–28.7] 26.1 [24.2–29.9] 0.50
Fat percentage (%)* 31.6 [26.2–38.5] 29.8 [24.9–37.8] 33.6 [27.4–39.2] 0.12
Handgrip strength (kg)* 38 [30–46] 40 [32–46] 38 [28–48] 0.39
Physical activity level (MET h/wk)* 140 [96–177] 134 [94–168] 146 [97–181] 0.41
Note: Data are presented as means ± SD or median [interquartile range]. An independent ttest or Mann–Whitney Utest was
used to examine differences between groups. Sex differences were examined using a
2
test. BMI, body mass index; CP, collagen
peptide.
*Not normally distributed data.
Pagination not final (cite DOI) / Pagination provisoire (citer le DOI)
4 Appl. Physiol. Nutr. Metab. Vol. 00, 0000
Published by NRC Research Press
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by RADBOUD UNIVERSITEIT NIJMEGEN on 06/25/20
For personal use only.
were found after supplementation in both groups (all p> 0.05),
except for an increased IL-6 concentration in the placebo group
(p= 0.012, Table 2).
Cartilage biomarkers
Baseline CTX-II and P2CP levels did not differ between both
groups (p= 0.27 and p= 0.72, respectively). After 12 weeks of
supplementation no change in CTX-II concentration was found in
both groups (p= 0.41 and p= 0.65 for the CP and placebo groups,
respectively), whereas the P2CP concentration was increased in
the CP (p= 0.013) and placebo groups (p= 0.032, Table 2). Moreover,
the increase in P2CP concentration did not differ between the CP
(2.8 [IQR = −3.4–10.3, 95% CI = 0.7–6.0] g/mL) and placebo groups
(4.6 [IQR = −3.8–9.9, 95% CI = −1.3–4.4] g/mL, p= 0.94, Table 2).
Bone biomarkers
Baseline CTX and PINP concentrations did not differ between
both groups (p= 0.56 and p= 0.92, respectively). We found in-
creased CTX levels after 12 weeks of supplementation in both
groups (p= 0.037 and p= 0.023 for the CP and placebo group,
respectively), whereas no differences in PINP concentration were
found (p= 0.71 and p= 0.94, Table 2). Moreover, the increase in CTX
concentration did not differ between the CP (0.022 [IQR = −0.029
to 0.070, 95% CI = −0.004 to 0.045] ng/mL) and placebo group (0.012
[IQR = −0.034 to 0.075, 95% CI = 0.002–0.040] ng/mL, p= 0.94,
Table 2).
Discussion
In this double-blind, randomized, placebo-controlled trial, we
examined the effects of 12 weeks of CP supplementation on knee
pain and function in healthy, physically active, middle-aged to
elderly individuals with self-reported knee pain. A reduced knee
pain and improved knee function were found after 12 weeks of
supplementation, but changes over time did not differ between
groups. Moreover, in a study by Wandel et al., a difference in VAS
score of 0.9 between measurements was defined as clinically rel-
evant (Wandel et al. 2010), which suggest that the change in VAS
after 12 weeks of supplementation (CP = −1.6 ± 2.4 and Placebo =
−1.9 ± 2.6) was not only not statistically different (p= 0.42), but also
not a clinically relevant difference between groups. Furthermore,
we did not find any difference in inflammatory, cartilage, and
bone (bio)markers after 12 weeks of supplementation between
both groups. The absence of a superior effect in the CP group
suggest that 12-weeks of CP supplementation did not contribute
to reductions in knee joint pain in healthy, physically active,
middle-aged to elderly individuals.
The main finding of our study was that we did not find a supe-
rior effect of 12 weeks of CP compared with placebo supplemen-
tation on knee pain and knee function. This is in contrast to most
(Bruyere et al. 2012;Kumar et al. 2015), but not all (Lugo et al. 2013),
previous studies. Bruyere and colleagues demonstrated that
6 months of collagen hydrolysate supplementation, in partici-
pants with joint pain (VAS > 3.0) at different joints (hip, knee,
elbow, shoulder, hand, or/and lumbar spine) without diagnosed
osteoarthritis, resulted in a greater proportion of participants
with a clinical decrement in VAS (≥20%) compared with the pla-
cebo group (Bruyere et al. 2012). Our study demonstrated that a
similar proportion of participants in the CP and placebo group
(60% vs. 67%, respectively) demonstrated a decreased VAS ≥
20%. Kumar et al. demonstrated in participants with diagnosed
osteoarthritis and a baseline VAS > 4.0 (average VAS 6.3 ± 1.1 and
6.6 ± 1.2) that 13 weeks of CP supplementation derived from either
pork skin or bovine bone resulted in an 51% and 58% decrease
in VAS, respectively (Kumar et al. 2015). In contrast, we included
Fig. 2. Knee pain measured with the Visual Analog Scale (VAS) at baseline
and week 12 and the response to supplementation (= week 12 − baseline)
for the collagen peptide (CP; white bars) and placebo group (grey bars).
Data are presented as median [interquartile range] (n= 167). A decrease in
VAS was found in both groups, while the magnitude of the decrease did
not differ between groups.
Fig. 3. Knee function measured with the Knee injury and Osteoarthritis
Outcome Score (KOOS; A) and Lysholm questionnaire (B) at baseline and
week 12 and the response to supplementation (= week 12 − baseline)
for the collagen peptide (CP; white bars) and placebo group (grey bars).
Data are presented as median [interquartile range] (n= 166). An increase in
KOOS and Lysholm score was found in both groups, while the magnitude
of the increase did not differ between groups.
Pagination not final (cite DOI) / Pagination provisoire (citer le DOI)
Bongers et al. 5
Published by NRC Research Press
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by RADBOUD UNIVERSITEIT NIJMEGEN on 06/25/20
For personal use only.
participants with a VAS > 1.0 for knee pain (average VAS 4.7 [IQR =
2.6–6.2, 95% CI = 4.2–4.8]) and did not find an effect of CP supple-
mentation. Our study population consisted of 43 participants
(n=19andn= 24 in CP and placebo, respectively) with a baseline
VAS > 6.0. Within this subgroup of participants we did not find
differences in VAS between groups, suggesting that the lower
baseline VAS in our study did not explain the lack of difference
between the CP and placebo groups. Although baseline VAS did
not seem to influence the results, participants with diagnosed
osteoarthritis have been excluded from participation in our study
and therefore only relatively mild cases might have been in-
cluded. Participants’ Lysholm score at baseline was 67 [IQR = 58–
74, 95% CI = 64–68], which corresponds to a fair knee function
(Briggs et al. 2009). Therefore, knee complaints and associated
decrements in knee function of our participants may not have
been severe enough to find a beneficial effect of CP supplementa-
tion.
Another potential explanation for the decrease in knee pain
and improvement in knee function outcomes in both the CP and
the placebo group could be the presence of a placebo effect in
both groups. Zhang and colleagues demonstrated an overall esti-
mate of the effect size for pain relief of 0.51 (95% CI = 0.46–0.55) in
studies focusing on osteoarthritis and pain (Zhang et al. 2008).
Moreover, in 1955 Beecher combined data from placebo groups of
15 studies and demonstrated that placebos on average led to a 35%
improvement in outcomes (Beecher 1955). Average improvement
after 12 weeks of CP or placebo supplementation in our study was
36% and 53%, respectively. Therefore, the decrease in knee
pain in both groups could mainly be attributed to a placebo effect.
Moreover, the presence of this large placebo effect in both groups
made it harder to find a significant difference between groups.
Additionally, in the present study a supplementation duration
of 12 weeks was used, while previous studies with a positive out-
come used a supplementation period of 24 weeks or longer
(Bruyere et al. 2012;Clark et al. 2008;Lugo et al. 2016). This may
suggest that long-term supplementation is needed to induce ben-
eficial effects on knee pain, even more so in elderly who may have
knee complaints for a long time already. However, 26% of the
participants had a VAS lower than the exclusion threshold
(VAS < 1) after 12 weeks of supplementation. These findings sug-
gest that elongation of the supplementation period would proba-
bly not affect the results within our cohort of middle-aged to
elderly physically active individuals.
We did not find a difference in inflammatory markers and bone
and cartilage biomarkers between the CP and placebo group,
which suggests that CP supplementation did not reduce the in-
flammatory status and did not stimulate bone formation or the
synthesis of cartilage. This finding is in line with previous preclin-
ical data that observed that the use of collagen hydrolysates does
not stimulate type II collagen biosynthesis in human articular
cartilage (Schadow et al. 2013,2017). In our study, baseline concen-
trations of the inflammatory markers were all within the reference
values and did not show evidence of whole-body inflammation
(Todd et al. 2013). We did find an increased IL-6 concentration in
the placebo group after 12 weeks of supplementation, while this
increase was absent in the CP group. The authors are not able to
explain the increased IL-6 concentration, and the increment is not
supported by other inflammatory markers (i.e., TNF-and CRP).
Furthermore, the IL-6 concentration in the placebo group post-
supplementation (0.7 [IQR = 0.5–0.9, 95% CI = 0.7–1.4]) was still
within the upper 95th percentile reference limit of 4.45 pg/mL
(Todd et al. 2013). The elevated levels of CTX and P2CP after
12 weeks of supplementation seem not to be the result of CP
supplementation since we did not find a difference between both
groups.
Strengths and limitations
A strength of the study is the design (double-blind, randomized,
and placebo-controlled) and the inclusion of a large study popu-
lation. Furthermore, the supplement compliance of the partici-
pants was very high (99.5% ± 1.3%, 95% CI = 99.3–99.7). However,
there are some limitations that should be taken into account.
First, we included participants with self-reported knee pain with-
out diagnosis of osteoarthritis. Since no X-rays were obtained it is
not certain that the participants had no osteoarthritis. Symptoms
of arthritis can fluctuate over time, which could have led to a large
heterogeneity within our study population. We tried to minimize
the heterogeneity by excluding participants with specific medical
conditions or supplement/medication intake. Moreover, all par-
ticipants were in preparation for a multiple-day prolonged exer-
cise event, which might suggest that our study population is a
relatively active and healthy population, and is probably not rep-
resentative for the general population with knee complaints. Fur-
thermore, we randomly allocated participants to the CP and
placebo group. Second, a total of 33 participants dropped out of
the study (i.e., 33 out of 200, 17%), whereas some (3 in total and
2 in the CP group) of these participants withdrew because of in-
creasing knee pain. Moreover, significantly more dropouts were
observed in the CP group (n= 23) compared with the placebo
group (n= 10, p= 0.013). However, the difference in dropout rate
can mainly (n= 16 out of 33, 50%) be attributed to a baseline
VAS < 1, which makes it unlikely that dropout was influenced by
the use of the CP supplement. As a consequence of the high drop-
out rate, the total number of participants in CP group (n= 77) was
lower than the number of participants needed according to the
sample size calculation (n= 86). However, based on current results
we did not expect a difference when more participants were in-
cluded. Although we did instruct participants to avoid using an-
algesics prior to the baseline measurements, we did not provide
specific instructions for analgesics and/or NSAID use during the
supplementation period. As a result, a total of 22 participants used
analgesics (primarily paracetamol; n= 15) on the day of the post-
Table 2. Within- and between-group differences in blood markers.
Collagen peptide Placebo Change during 12 weeks of supplementation
Baseline Week 12 pBaseline Week 12 pCP Placebo p
IL-6 (pg/mL) 0.6 [0.4 to 0.8] 0.6 [0.5 to 0.9] 0.11 0.5 [0.4 to 0.8] 0.7 [0.5 to 0.9] 0.012 0.05 [−0.14 to 0.21] 0.07 [−0.09 to 0.25] 0.56
TNF-(pg/mL) 1.9 [1.6 to 2.4] 1.9 [1.6 to 2.4] 0.85 1.9 [1.5 to 2.2] 1.9 [1.5 to 2.3] 0.71 0.01 [−0.27 to 0.24] −0.09 [−0.23 to 0.25] 0.90
MCP-1 (pg/mL) 369 [300 to 457] 366 [311 to 453] 0.68 356 [289 to 438] 371 [317 to 433] 0.50 −1.8 [−44.2 to 40.9] 4.8 [−48.7 to 58.5] 0.45
CRP (g/mL) 1.9 [1.1 to 4.2] 1.7 [0.8 to 3.2] 0.09 2.1 [1.0 to 3.8] 1.8 [0.9 to 3.5] 0.52 −0.1 [−1.7 to 0.5] −0.1 [−1.1 to 0.6] 0.35
CTX-II (pg/mL) 421 [346 to 527] 434 [355 to 528] 0.41 419 [333 to 499] 412 [354 to 511] 0.65 3.7 [−26.5 to 45.1] 1.0 [−45.3 to 53.9] 0.83
P2CP (ng/mL) 20.8 [14.8 to 28.5] 24.3 [16.3 to 31.1] 0.013 21.7 [15.6 to 28.2] 25.5 [16.9 to 30.0] 0.032 2.8 [−3.4 to 10.3] 4.6 [−3.8 to 9.9] 0.94
CTX (ng/mL) 0.2 [0.1 to 0.3] 0.2 [0.2 to 0.3] 0.037 0.2 [0.1 to 0.3] 0.2 [0.2 to 0.3] 0.023 0.02 [−0.03 to 0.07] 0.01 [−0.03 to 0.08] 0.94
PINP (ng/mL) 42.5 [34.5 to 55.4] 42.4 [34.4 to 56.3] 0.71 43.2 [34.0 to 55.6] 42.5 [34.3 to 56.3] 0.94 1.1 [−4.6 to 4.5] 0.2 [−5.4 to 5.5] 0.92
Note: Data are presented as median [interquartile range]. Inflammatory, bone, and cartilage (bio)markers at baseline and after 12 weeks of supplementation. A
nonparametric Wilcoxon signed-rank test was used to assess differences within groups, whilst a Mann–Whitney Utest was used to assess differences between groups.
CTX, carboxy-terminal telopeptides; CTX-II, C-terminal cross-linked telopeptide type II collagen; IL-6, interleukin 6; MCP-1, monocyte chemoattractant protein-1; P2CP,
procollagen II C-terminal propeptide; PINP, procollagen I intact N-terminal; TNF-, tumor necrosis factor alpha.
Pagination not final (cite DOI) / Pagination provisoire (citer le DOI)
6 Appl. Physiol. Nutr. Metab. Vol. 00, 0000
Published by NRC Research Press
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by RADBOUD UNIVERSITEIT NIJMEGEN on 06/25/20
For personal use only.
supplementation measurements, which may have influenced our
findings. However, when we exclude these participants in a sen-
sitivity analyses, similar outcomes were observed (change in VAS
for knee pain after 12 weeks of supplementation was −1.7 ± 2.3 and
−2.1 ± 2.5 for CP and control groups, respectively, p= 0.33). As the
use of analgesics did not impact our study findings, we decided to
keep the participants who used analgesics in our analysis. Fur-
thermore, we did not monitor the participants’ food intake
throughout the study. Since CP is a hydrolyzed form of gelatin (Liu
et al. 2015), it is possible, but quite unlikely, that a high CP con-
sumption in daily life (desserts, bakery products, gummy candy)
affects the outcomes of the study. Furthermore, such bias may
have affected the CP and placebo group equally.
Conclusion
In conclusion, 12 weeks of CP and placebo supplementation
resulted in a similar reduction in knee pain and improvement of
knee function. The absence of a superior effect of CP suggest that
CP supplementation over a 12-week period does not reduce knee
joint pain in healthy, physically active, middle-aged to elderly
individuals with self-reported knee pain.
Conflicts of interest statement
The work of T.M.H. Eijsvogels is supported by a European Com-
mission Horizon 2020 grant (Marie Sklodowska-Curie Fellowship
655502) and the work by J.A. Wouters is supported by the Province
of Gelderland (PS2014-49). Furthermore, this investigator-initiated
study (Radboudumc) was supported by Rousselot (Gent, Belgium),
in which the complete study, including research design, data col-
lection, data analysis, was performed by the research team and
not influenced by our funding partner. All other authors have
nothing to declare.
Acknowledgements
We recognize the excellent help of the organization of the Ni-
jmegen Four Days Marches. Furthermore, we want to thank the
Wageningen University & Research (WUR) and the Leiden Univer-
sity Medical Center (LUMC) for their assistance with the blood
sample analysis. The authors greatly acknowledge the enthusiasm
and dedication of the participants in this study. Furthermore, the
practical assistance of colleagues was greatly appreciated.
References
Beecher, H.K. 1955. The powerful placebo. J. Am. Med. Assoc. 159(17): 1602–1606.
doi:10.1001/jama.1955.02960340022006. PMID:13271123.
Briggs, K.K., Lysholm, J., Tegner, Y., Rodkey, W.G., Kocher, M.S., and
Steadman, J.R. 2009. The reliability, validity, and responsiveness of the Lysh-
olm score and Tegner activity scale for anterior cruciate ligament injuries of
the knee: 25 years later. Am. J. Sports Med. 37(5): 890–897. doi:10.1177/
0363546508330143. PMID:19261899.
Bruyere, O., Zegels, B., Leonori, L., Rabenda, V., Janssen, A., Bourges, C., and
Reginster, J.Y. 2012. Effect of collagen hydrolysate in articular pain: a
6-month randomized, double-blind, placebo controlled study. Complement.
Ther. Med. 20(3): 124–130. doi:10.1016/j.ctim.2011.12.007. PMID:22500661.
Clark, K.L., Sebastianelli, W., Flechsenhar, K.R., Aukermann, D.F., Meza, F.,
Millard, R.L., et al. 2008. 24-Week study on the use of collagen hydrolysate as
a dietary supplement in athletes with activity-related joint pain. Curr. Med.
Res. Opin. 24(5): 1485–1496. doi:10.1185/030079908X291967. PMID:18416885.
Cohen, N.P., Foster, R.J., and Mow, V.C. 1998. Composition and dynamics of
articular cartilage: structure, function, and maintaining healthy state. J. Orthop.
Sports Phys. Ther. 28(4): 203–215. doi:10.2519/jospt.1998.28.4.203. PMID:9785256.
Collins, N.J., Prinsen, C.A., Christensen, R., Bartels, E.M., Terwee, C.B., and
Roos, E.M. 2016. Knee Injury and Osteoarthritis Outcome Score (KOOS): sys-
tematic review and meta-analysis of measurement properties. Osteoarthritis
Cartilage, 24(8): 1317–1329. doi:10.1016/j.joca.2016.03.010. PMID:27012756.
Conrozier, T., Poole, A.R., Ferrand, F., Mathieu, P., Vincent, F., Piperno, M., et al.
2008. Serum concentrations of type II collagen biomarkers (C2C, C1, 2C and
CPII) suggest different pathophysiologies in patients with hip osteoarthritis.
Clin. Exp. Rheumatol. 26(3): 430–435. PMID:18578964.
Dar, Q.A., Schott, E.M., Catheline, S.E., Maynard, R.D., Liu, Z.Y., Kamal, F., et al.
2017. Daily oral consumption of hydrolyzed type 1 collagen is chondroprotec-
tive and anti-inflammatory in murine posttraumatic osteoarthritis. PLoS
One, 12(4): e0174705. doi:10.1371/journal.pone.0174705. PMID:28384173.
DuRaine, G., Neu, C.P., Chan, S.M., Komvopoulos, K., June, R.K., and Reddi, A.H.
2009. Regulation of the friction coefficient of articular cartilage by TGF-beta1
and IL-1beta. J. Orthop. Res. 27(2): 249–256. doi:10.1002/jor.20713. PMID:
18683879.
Durnin, J.V., and Womersley, J. 1974. Body fat assessed from total body density
and its estimation from skinfold thickness: measurements on 481 men and
women aged from 16 to 72 years. Br. J. Nutr. 32(1): 77–97. doi:10.1079/
BJN19740060. PMID:4843734.
Fraser, A., Fearon, U., Billinghurst, R.C., Ionescu, M., Reece, R., Barwick, T., et al.
2003. Turnover of type II collagen and aggrecan in cartilage matrix at the
onset of inflammatory arthritis in humans: relationship to mediators of
systemic and local inflammation. Arthritis Rheum. 48(11): 3085–3095. doi:10.
1002/art.11331. PMID:14613270.
Goldring, M.B., and Berenbaum, F. 2004. The regulation of chondrocyte function
by proinflammatory mediators: prostaglandins and nitric oxide. Clin. Orthop.
Relat. Res. 427(Suppl.): S37–S46. doi:10.1097/01.blo.0000144484.69656.e4. PMID:
15480072.
Goldring, S.R., and Goldring, M.B. 2004. The role of cytokines in cartilage matrix
degeneration in osteoarthritis. Clin. Orthop. Relat. Res. 427(Suppl.): S27–S36.
doi:10.1097/01.blo.0000144854.66565.8f. PMID:15480070.
Haefeli, M., and Elfering, A. 2006. Pain assessment. Eur. Spine J. 15(Suppl. 1):
S17–S24. doi:10.1007/s00586-005-1044-x. PMID:16320034.
Hawker, G.A., Mian, S., Kendzerska, T., and French, M. 2011. Measures of Adult
Pain Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain
(NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Ques-
tionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily
Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoar-
thritis Pain (ICOAP). Arthrit. Care Res. 63(S11): S240–S252. doi:10.1002/acr.
20543. PMID:22588748.
Iozzo, R.V., and Murdoch, A.D. 1996. Proteoglycans of the extracellular environ-
ment: clues from the gene and protein side offer novel perspectives in mo-
lecular diversity and function. FASEB J. 10(5): 598–614. doi:10.1096/fasebj.10.
5.8621059. PMID:8621059.
Iozzo, R.V., and Schaefer, L. 2015. Proteoglycan form and function: a comprehen-
sive nomenclature of proteoglycans. Matrix Biol. 42: 11–55. doi:10.1016/j.
matbio.2015.02.003. PMID:25701227.
Jiang, J.X., Yu, S., Huang, Q.R., Zhang, X.L., Zhang, C.Q., Zhou, J.L., and Prawitt, J.
2014. Collagen peptides improve knee osteoarthritis in elderly women A
6-month randomized, double-blind, placebo-controlled study. Agro. Food
Ind. Hi Tec. 25(2): 19–23.
Kumar, S., Sugihara, F., Suzuki, K., Inoue, N., and Venkateswarathirukumara, S.
2015. A double-blind, placebo-controlled, randomised, clinical study on the
effectiveness of collagen peptide on osteoarthritis. J. Sci. Food Agric. 95(4):
702–707. doi:10.1002/jsfa.6752. PMID:24852756.
Liu, D.S., Nikoo, M., Boran, G., Zhou, P., and Regenstein, J.M. 2015. Collagen and
Gelatin. Annu. Rev. Food Sci. Techonol. 6: 527–557. doi:10.1146/annurev-food-
031414-111800. PMID:25884286.
Luftner, D., Jozereau, D., Schildhauer, S., Geppert, R., Muller, C., Fiolka, G., et al.
2005. PINP as serum marker of metastatic spread to the bone in breast cancer
patients. Anticancer Res. 25(3A): 1491–1499. PMID:16033050.
Lugo, J.P., Saiyed, Z.M., Lau, F.C., Molina, J.P., Pakdaman, M.N., Shamie, A.N., and
Udani, J.K. 2013. Undenatured type II collagen (UC-II(R®)) for joint support: a
randomized, double-blind, placebo-controlled study in healthy volunteers.
J. Int. Soc. Sports Nutr. 10(1): 48. doi:10.1186/1550-2783-10-48. PMID:24153020.
Lugo, J.P., Saiyed, Z.M., and Lane, N.E. 2016. Efficacy and tolerability of an unde-
natured type II collagen supplement in modulating knee osteoarthritis
symptoms: a multicenter randomized, double-blind, placebo-controlled
study. Nutr. J. 15: 14. doi:10.1186/s12937-016-0130-8. PMID:26822714.
Lumachi, F., Santeufemia, D.A., Del Conte, A., Mazza, F., Tozzoli, R., Chiara, G.B.,
and Basso, S.M. 2013. Carboxy-terminal Telopeptide (CTX) and Amino-
terminal Propeptide (PINP) of Type I collagen as markers of bone metastases
in patients with non-small cell lung cancer. Anticancer Res. 33(6): 2593–2596.
PMID:23749913.
McAlindon, T.E., Nuite, M., Krishnan, N., Ruthazer, R., Price, L.L., Burstein, D.,
et al. 2011. Change in knee osteoarthritis cartilage detected by delayed gado-
linium enhanced magnetic resonance imaging following treatment with
collagen hydrolysate: a pilot randomized controlled trial. Osteoarthritis Car-
tilage, 19(4): 399–405. doi:10.1016/j.joca.2011.01.001. PMID:21251991.
Moskowitz, R.W. 2000. Role of collagen hydrolysate in bone and joint disease.
Semin. Arthritis Rheum. 30(2): 87–99. doi:10.1053/sarh.2000.9622. PMID:
11071580.
Mueller, M.B., and Tuan, R.S. 2011. Anabolic/Catabolic balance in pathogenesis of
osteoarthritis: identifying molecular targets. PM&R, 3(6 Suppl. 1): S3–S11.
doi:10.1016/j.pmrj.2011.05.009. PMID:21703577.
Nicolaou, M., Gademan, M.G.J., Snijder, M.B., Engelbert, R.H.H., Dijkshoorn, H.,
Terwee, C.B., and Stronks, K. 2016. Validation of the SQUASH physical activity
questionnaire in a multi-ethnic population: the HELIUS study. PLoS ONE,
11(8): e0161066. doi:10.1371/journal.pone.0161066. PMID:27575490.
Oesser, S., and Seifert, J. 2003. Stimulation of type II collagen biosynthesis and
secretion in bovine chondrocytes cultured with degraded collagen. Cell Tis-
sue Res. 311(3): 393–399. doi:10.1007/s00441-003-0702-8. PMID:12658447.
Pearle, A.D., Scanzello, C.R., George, S., Mandl, L.A., DiCarlo, E.F., Peterson, M.,
et al. 2007. Elevated high-sensitivity C-reactive protein levels are associated
Pagination not final (cite DOI) / Pagination provisoire (citer le DOI)
Bongers et al. 7
Published by NRC Research Press
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by RADBOUD UNIVERSITEIT NIJMEGEN on 06/25/20
For personal use only.
with local inflammatory findings in patients with osteoarthritis. Osteoarthri-
tis Cartilage, 15(5): 516–523. doi:10.1016/j.joca.2006.10.010. PMID:17157039.
Roos, E.M., Roos, H.P., Lohmander, L.S., Ekdahl, C., and Beynnon, B.D. 1998. Knee
injury and osteoarthritis outcome score (KOOS)–development of a self-
administered outcome measure. J. Orthop. Sports Phys. Ther. 28(2): 88–96.
doi:10.2519/jospt.1998.28.2.88. PMID:9699158.
Rotterud, J.H., Reinholt, F.P., Beckstrom, K.J., Risberg, M.A., and Aroen, A. 2014.
Relationship between CTX-II and patient characteristics, patient-reported
outcome, muscle strength, and rehabilitation in patients with a focal carti-
lage lesion of the knee: a prospective exploratory cohort study of 48 patients.
BMC Musculoskelet. Disord. 15: 99. doi:10.1186/1471-2474-15-99. PMID:24661577.
Sato, K. 2017. The presence of food-derived collagen peptides in human body-
structure and biological activity. Food Funct. 8(12): 4325–4330. doi:10.1039/
c7fo01275f. PMID:29114654.
Schadow, S., Siebert, H.C., Lochnit, G., Kordelle, J., Rickert, M., and Steinmeyer, J.
2013. Collagen metabolism of human osteoarthritic articular cartilage as
modulated by bovine collagen hydrolysates. PLoS ONE, 8(1): e53955. doi:10.
1371/journal.pone.0053955. PMID:23342047.
Schadow, S., Simons, V.S., Lochnit, G., Kordelle, J., Gazova, Z., Siebert, H.C., et al.
2017. Metabolic response of human osteoarthritic cartilage to biochemically
characterized collagen hydrolysates. Int. J. Mol. Sci. 18(1): E207. doi:10.3390/
ijms18010207. PMID:28117674.
Scheller, J., Chalaris, A., Schmidt-Arras, D., and Rose-John, S. 2011. The pro- and
anti-inflammatory properties of the cytokine interleukin-6. Biochim. Biophys. Acta,
1813(5): 878–888. doi:10.1016/j.bbamcr.2011.01.034. PMID:21296109.
Simons, V.S., Lochnit, G., Wilhelm, J., Ishaque, B., Rickert, M., and Steinmeyer, J.
2018. Comparative analysis of peptide composition and bioactivity of differ-
ent collagen hydrolysate batches on human osteoarthritic synoviocytes. Sci.
Rep. 8(1): 17733. doi:10.1038/s41598-018-36046-3. PMID:30531866.
Sophia Fox, A.J., Bedi, A., and Rodeo, S.A. 2009. The basic science of articular
cartilage: structure, composition, and function. Sports Health, 1(6): 461–468.
doi:10.1177/1941738109350438. PMID:23015907.
Todd, J., Simpson, P., Estis, J., Torres, V., and Wub, A.H. 2013. Reference range
and short- and long-term biological variation of interleukin (IL)-6, IL-17A and
tissue necrosis factor-alpha using high sensitivity assays. Cytokine, 64(3):
660–665. doi:10.1016/j.cyto.2013.09.018. PMID:24128872.
Villiger, P.M., Terkeltaub, R., and Lotz, M. 1992. Monocyte chemoattractant
protein-1 (MCP-1) expression in human articular cartilage. Induction by pep-
tide regulatory factors and differential effects of dexamethasone and retinoic
acid. J. Clin. Invest. 90(2): 488–496. doi:10.1172/JCI115885. PMID:1365641.
Wandel, S., Juni, P., Tendal, B., Nuesch, E., Villiger, P.M., Welton, N.J., et al. 2010.
Effects of glucosamine, chondroitin, or placebo in patients with osteoarthri-
tis of hip or knee: network meta-analysis. BMJ, 341: c4675. doi:10.1136/bmj.
c4675. PMID:20847017.
Wojdasiewicz, P., Poniatowski, L.A., and Szukiewicz, D. 2014. The role of inflam-
matory and anti-inflammatory cytokines in the pathogenesis of osteoarthri-
tis. Mediat. Inflamm. 2014: 561459. doi:10.1155/2014/561459. PMID:24876674.
Zdzieblik, D., Oesser, S., Gollhofer, A., and Koenig, D. 2016. Collagen peptides
reduce knee joint discomfort in physically active young adults. Int. J. Sports
Exerc. Med. 2: 041.
Zhang, W., Robertson, J., Jones, A.C., Dieppe, P.A., and Doherty, M. 2008. The
placebo effect and its determinants in osteoarthritis: meta-analysis of ran-
domised controlled trials. Ann. Rheum. Dis. 67(12): 1716–1723. doi:10.1136/ard.
2008.092015. PMID:18541604.
Pagination not final (cite DOI) / Pagination provisoire (citer le DOI)
8 Appl. Physiol. Nutr. Metab. Vol. 00, 0000
Published by NRC Research Press
Appl. Physiol. Nutr. Metab. Downloaded from www.nrcresearchpress.com by RADBOUD UNIVERSITEIT NIJMEGEN on 06/25/20
For personal use only.
... Articular cartilage plays a vital role in the function of the musculoskeletal system by allowing almost frictionless motion to occur between the articular surfaces of a diarthrodial (synovial) joint (14). Furthermore, articular cartilage distributes the loads of articulation over a larger contact area, thereby minimizing the contact stresses, and dissipates the energy associated with the load (74). ...
... Collagen is an ubiquitous biomaterial found in numerous tissues, including articular cartilage, bone, muscle, tendons, ligaments, menisci, and blood vessels. The predominant collagen type in articular cartilage, accounting for approximately 90-95%, is known as type I1 (14), while types VI, IX, X, and XI are also found to lesser extents. Collagen is dispersed throughout the ground substance in the extracellular matrix and is formed by three polypeptide chains that are cross-linked covalently (23). ...
Article
Disorders of articular cartilage represent some of the most common and debilitating diseases encountered in orthopaedic practice. Understanding the normal functioning of articular cartilage is a prerequisite to understanding its pathologic processes. The mechanical properties of articular cartilage arise from the complex structure and interactions of its biochemical constituents: mostly water, electrolytes, and a solid matrix composed primarily of collagen and proteoglycan. The viscoelastic properties of cartilage, due primarily to fluid flow through the solid matrix, can explain much of the deformational responses observed under many loading conditions. Degenerative processes can often be explained by a breakdown of the normal load-bearing capacity of cartilage which arises from the mechanics of this fluid flow. Several factors which may lead to such a breakdown include direct trauma to the cartilage, obesity, immobilization, and excessive repetitive loading of the cartilage. Sports activity, without traumatic injury, does not appear to be a risk factor for the development of osteoarthritis in the normal joint; however, such activity may be harmful to an abnormal joint.
... 34 As outlined in 2000 by Moskowitz [32], a form of oral collagen known as collagen hydrolysate is of particular interest as a therapeutic agent in efforts to treat osteoarthritis more effectively due to its high safety level, even when used for long periods. Although disputed by Bongers., et al. [37] who found collagen peptide did not reduce pain in active middle aged to healthy subjects with knee pain complaints, Bakilan., et al. [28] found collagen added to acetaminophen to improve the efficacy of this painkiller in a similar sample. ...
Article
Full-text available
This mini review aimed to examine support for the alternate hypothesis that collagen supplements can help to ameliorate osteoarthritis pain significantly and effectively.
Article
Full-text available
Collagen hydrolysates (CHs) are heterogeneous mixtures of collagen peptides that are often used as nutraceuticals for osteoarthritis (OA). In this study, we compared the peptide composition and pharmacological effects of three different CH preparations (CH-Alpha®, Peptan® B 2000 and Mobiforte®) as well as their production batches. Our biochemical analysis using MALDI-TOF mass spectrometry and the ICPL™-isotope labelling method revealed marked differences between different CH preparations and even between some production batches of the same preparation. We also investigated the pharmacological effects of these CHs on human fibroblast-like synoviocytes (FLS). No significant effects on cultured FLS could be demonstrated for either production batch of CHAlpha ®, Peptan® B 2000, and Mobiforte® analyzing a small number of pharmacological relevant targets. Thus, our study already shows for the first time that different production batches of the same CH preparation as well as different CH preparations can differ significantly in their peptide composition. In this line, further studies are also needed to verify equal pharmacological efficacy of CH batches on a much broader range of (patho)physiological relevant targets. If OA patients are to be offered a safe and effective nutraceutical a better knowledge about all potential effects as well as ensuring the same active-substance levels are a prerequisite.
Article
Full-text available
It has been demonstrated that ingestion of some protein hydrolysates exerts health-promoting effects. For understanding the underlying mechanisms responsible for these effects, identification of the bioactive peptides in the target organ is crucial. For this purpose, in vitro activity-guided fractionation for peptides in the protein hydrolysate has been performed. However, the peptides in the hydrolysate may be further degraded during digestion. Concentration of the active peptides, which were identified by in vitro activity-guided fractionation, in human blood is frequently very low (nanomolar levels). In contrary, micromolar levels of food-derived collagen peptides are present in the human blood. Pro–Hyp, one of the major food-derived collagen peptides, enhances the growth of fibroblasts and synthesis of hyaluronic acid. These observations partially explain the beneficial effects of collagen hydrolysates ingestion on the enhancement of wound healing and improvement in the skin condition. The recent advancement involving liquid chromatography and mass spectrometry coupled with the pre-column derivatization technique has enabled the identification of food-derived peptides at nanmolar levels in the body post-ingestion of protein hydrolysates. Thus, this technique can be used for identification of bioactive food-derived peptides in the body.
Article
Full-text available
Osteoarthritis (OA) is a degenerative joint disease for which there are no disease modifying therapies. Thus, strategies that offer chondroprotective or regenerative capability represent a critical unmet need. Recently, oral consumption of a hydrolyzed type 1 collagen (hCol1) preparation has been reported to reduce pain in human OA and support a positive influence on chondrocyte function. To evaluate the tissue and cellular basis for these effects, we examined the impact of orally administered hCol1 in a model of posttraumatic OA (PTOA). In addition to standard chow, male C57BL/6J mice were provided a daily oral dietary supplement of hCol1 and a meniscal-ligamentous injury was induced on the right knee. At various time points post-injury, hydroxyproline (hProline) assays were performed on blood samples to confirm hCol1 delivery, and joints were harvested for tissue and molecular analyses were performed, including histomorphometry, OARSI and synovial scoring, immunohistochemistry and mRNA expression studies. Confirming ingestion of the supplements, serum hProline levels were elevated in experimental mice administered hCol1. In the hCol1 supplemented mice, chondroprotective effects were observed in injured knee joints, with dose-dependent increases in cartilage area, chondrocyte number and proteoglycan matrix at 3 and 12 weeks post-injury. Preservation of cartilage and increased chondrocyte numbers correlated with reductions in MMP13 protein levels and apoptosis, respectively. Supplemented mice also displayed reduced synovial hyperplasia that paralleled a reduction in Tnf mRNA, suggesting an anti-inflammatory effect. These findings establish that in the context of murine knee PTOA, daily oral consumption of hCol1 is chondroprotective, anti-apoptotic in articular chondrocytes, and anti-inflammatory. While the underlying mechanism driving these effects is yet to be determined, these findings provide the first tissue and cellular level information explaining the already published evidence of symptom relief supported by hCol1 in human knee OA. These results suggest that oral consumption of hCol1 is disease modifying in the context of PTOA.
Article
Full-text available
The most frequent disease of the locomotor system is osteoarthritis (OA), which, as a chronic joint disease, might benefit more from nutrition than acute illnesses. Collagen hydrolysates (CHs) are peptidic mixtures that are often used as nutraceuticals for OA. Three CHs were characterized biochemically and pharmacologically. Our biophysical (MALDI-TOF-MS, NMR, AFM) and fluorescence assays revealed marked differences between CHs of fish (Peptan® F 5000, Peptan® F 2000) and porcine (Mobiforte®) origin with respect to the total number of peptides and common peptides between them. Using a novel dual radiolabeling procedure, no CH modulated collagen biosynthesis in human knee cartilage explants. Peptan® F 2000 enhanced the activities of the aggrecanase ADMATS4 and ADMATS5 in vitro without loss of proteoglycan from cartilage explants; the opposite effect was observed with Mobiforte®. Interleukin (IL)-6, matrix metalloproteinase (MMP)-1,-3 and-13 levels were elevated in explants that were treated with Mobiforte® and Peptan® F 5000, but not with Peptan® F 2000. In conclusion, the heterogeneous peptide composition and disparate pharmacological effects between CHs suggest that the effect of a CH preparation cannot be extrapolated to other formulations. Thus, the declaration of a CH as a safe and effective nutraceutical requires a thorough examination of its pleiotropic effects.
Article
Full-text available
Purpose: To investigate the reliability and validity of the SQUASH physical activity (PA) questionnaire in a multi-ethnic population living in the Netherlands. Methods: We included participants from the HELIUS study, a population-based cohort study. In this study we included Dutch (n = 114), Turkish (n = 88), Moroccan (n = 74), South-Asian Surinamese (n = 98) and African Surinamese (n = 91) adults, aged 18-70 years. The SQUASH was self-administered twice to assess test-re-test reliability (mean interval 6-7 weeks) and participants wore an accelerometer and heart rate monitor (Actiheart) to enable assessment of construct validity. Results: We observed low test-re-test reliability; Intra class correlation coefficients ranged from low (0.05 for moderate/high intensity PA in African Surinamese women) to acceptable (0.78 for light intensity PA in Moroccan women). The discrepancy between self-reported and measured PA differed on the basis of the intensity of activity: self-reported light intensity PA was lower than measured but self-reported moderate/high intensity PA was higher than measured, with wide limits of agreement. The discrepancy between questionnaire and Actiheart measures of moderate intensity PA did not differ between ethnic minority and Dutch participants with correction for relevant confounders. Additionally, the SQUASH overestimated the number of participants meeting the Dutch PA norm; Cohen's kappas for the agreement were poor, the highest being 0.30 in Dutch women. Conclusion: We found considerable variation in the test-re-test reliability and validity of self-reported PA with no consistency based on ethnic origin. Our findings imply that the SQUASH does not provide a valid basis for comparison of PA between ethnic groups.
Article
Full-text available
Background Undenatured type II collagen (UC-II) is a nutritional supplement derived from chicken sternum cartilage. The purpose of this study was to evaluate the efficacy and tolerability of UC-II for knee osteoarthritis (OA) pain and associated symptoms compared to placebo and to glucosamine hydrochloride plus chondroitin sulfate (GC). Methods One hundred ninety one volunteers were randomized into three groups receiving a daily dose of UC-II (40 mg), GC (1500 mg G & 1200 mg C), or placebo for a 180-day period. The primary endpoint was the change in total Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) from baseline through day 180 for the UC-II group versus placebo and GC. Secondary endpoints included the Lequesne Functional Index (LFI), the Visual Analog Scale (VAS) for pain and the WOMAC subscales. Modified intent-to-treat analysis were performed for all endpoints using analysis of covariance and mixed model repeated measures, while incremental area under the curve was calculated by the intent-to-treat method. ResultsAt day 180, the UC-II group demonstrated a significant reduction in overall WOMAC score compared to placebo (p = 0.002) and GC (p = 0.04). Supplementation with UC-II also resulted in significant changes for all three WOMAC subscales: pain (p = 0.0003 vs. placebo; p = 0.016 vs. GC); stiffness (p = 0.004 vs. placebo; p = 0.044 vs. GC); physical function (p = 0.007 vs. placebo). Safety outcomes did not differ among the groups. ConclusionUC-II improved knee joint symptoms in knee OA subjects and was well-tolerated. Additional studies that elucidate the mechanism for this supplement’s actions are warranted. Trial registrationCTRI/2013/05/003663; CTRI/2013/02/003348.
Article
Full-text available
As the global population gets older, joint-related health concerns are increasingly common, such as osteoarthritis causing pain and reducing mobility. Collagen peptides have been proposed as nutraceuticals to improve joint health in patients with osteoarthritis. We performed a prospective, randomized, double-blind, placebocontrolled study in elderly women with mild-to-moderate knee osteoarthritis and showed that the oral intake of collagen peptides (Peptan®) for a duration of 6 months significantly reduces joint pain and improves physical mobility as assessed by two wellestablished scoring systems (WOMAC and Lysholm score). This study confirms that collagen peptides are a highly efficient nutraceutical to improve joint health which can help to maintain an active lifestyle throughout ageing.
Article
Objective: To conduct a systematic review and meta-analysis to synthesise evidence regarding measurement properties of the Knee injury and Osteoarthritis Outcome Score (KOOS). Design: A comprehensive literature search identified 37 eligible papers evaluating KOOS measurement properties in participants with knee injuries and/or osteoarthritis. Methodological quality was evaluated using the COSMIN checklist. Where possible, meta-analysis of extracted data was conducted for all studies and stratified by age and knee condition; otherwise narrative synthesis was performed. Results: KOOS has adequate internal consistency, test-retest reliability and construct validity in young and old adults with knee injuries and/or osteoarthritis. The ADL subscale has better content validity for older patients and Sport/Rec for younger patients with knee injuries, while the Pain subscale is more relevant for painful knee conditions. The five-factor structure of the original KOOS is unclear. There is some evidence that the KOOS subscales demonstrate sufficient unidimensionality, but this requires confirmation. Although measurement error requires further evaluation, the minimal detectable change for KOOS subscales ranges from 14.3 to 19.6 for younger individuals, and ≥20 for older individuals. Evidence of responsiveness comes from larger effect sizes following surgical (especially total knee replacement) than non-surgical interventions. Conclusions: KOOS demonstrates adequate content validity, internal consistency, test-retest reliability, construct validity and responsiveness for age- and condition-relevant subscales. Structural validity, cross-cultural validity and measurement error require further evaluation, as well as construct validity of KOOS-PS. Suggested order of subscales for different knee conditions can be applied in hierarchical testing of endpoints in clinical trials.