Some aspects of “ Pseudogout ” with homoepathic mode of treatment

Also known as Calcium pyrophosphate deposition (CPPD) disease, pseudogout is an arthrpathy due to deposition of calcium pyrophosphate dihydrate (CPPD) crystals in articular cartilage & periarticular tissue & has many similarities with gout. Pseudogout has been reported to occasionally coexist with gout. This means that the two types of crystals can sometimes be found in the same joint fluid.

Sex- It occurs slightly more commonly in men.

Age- It usually occurs after the age of 60 years. But those with familial chondrocalcinosis may be affected at younger ages.

Aetiology- Aetiology of pseudogout is unknown but there is an association with primary hyperparathyroidism, haemochromatosis, ochronosis, amyloidosis, & hypothyroidism

Risk factors-
(1) Older age- Chance of developing the disease increases with age.
(2) Joint trauma- Trauma to a joint such as a serious injury or a joint replacement surgery, increases the risk of deposition CPPD crystals in the joints.
(3) Family history -Chance of developing pseudogout increases in case of a family history of the disease.

Site of lesion - Larger joints are more affected. In a majority of patients the knee joints are involved. Other areas commonly involved are elbows, wrists, ankles, shoulder & hip.

Associated medical conditions- Hyperparathyroidism, haemochromatosis, amyloidosis, hypothyroidism, hypophosphatasia & true gout.

Clinical Features- The clinical presentation is similar to that of normal gout, however, the onset is much slower, & its course is much milder. The attack begins suddenly with pain & swelling. The affected joint is warm & swollen with a large effusion. The pain may last for days to weeks & can resolve spontaneously. Pseudogout tends to be polyarticular but symmetrical involvement of joints is usually unlikely. Occasionally pyrophosphate deposition may be totally asymptomatic.

Investigations-
(1) Blood test- Serum calcium is normal. ESR may be raised during an attack.
(2) Analysis of Joint fluid- Joint fluid from an affected joint examined under a polarizing microscope if reveals the presence of calcium pyrophosphate crystals, diagnosis is confirmed.
(3) X-ray & MRI - X-ray & MRI, though cannot provide diagnostic confirmation of the disease, may be advocated to rule out other causes of pain & presence of associated medical conditions. They are also helpful to evaluate the extent of the disease & to detect possible damage to bone & surrounding structures. X –ray may also show calcifications in cartilage of joints referred to as chondrocalcinosis.

Differential Diagnosis- Pseudogout is to be differentiated from rheumatoid arthritis, osteoarthritis, gout, psoriatic arthritis, septic arthritis etc।

Treatment-

[A] General measures to be taken are-

(1) Cold compresses on painful joints.
(2) Complete rest.
(3) Exercise after the pain subsides.

[B] Homeopathic medicines to be used – Of the different homeopathic medicines commonly used, Aconite, Benzoicum acidum, Bryonia, Calcarea phos, Colchicum, Formica rufa, Rhus toxicodendron (Rhus.tox),ledum pal, etc. need to be mentioned. The use of the medicines is more or less the same as that in gout. The potency & frequency of dosage as well as duration of treatment varies with the severity of the condition & the individual along with type of gout whether it is acute or chronic. Lower potency is to be used at the beginning. If response is not satisfactory a second dose should be used. If desired effect is still not noticed, it is better to switch over to a new medicine.

Prevention-It is not known how to prevent pseudogout. If the condition has developed because of some other medical conditions, such as haemochromatosis, treatment of that condition may prevent progression of other features of that potentially dangerous illness & may in some cases, slow the development of pseudogout.

Prognosis- Often the inflamed joints heal without any residual damage but in many people permanent damage may occur with severe destruction of some joints. Pseudogout often complicates osteoarthritis, particularly in the knees & hips.


In short, pseugout is manifested by intense joint pain & swelling involving a single or multiple joints, & is to be treated by Aconite, Benzoicum acidum, Bryonia, Calcarea phos, Colchicum, Formica rufa, Rhus.tox etc.

But in every case, a doctor should be consulted.

Some aspects of “ Gout ” with homoepathic mode of treatment

Gout which may manifest as acute or chronic is an abnormality of uric acid metabolism which results in the precipitation of crystals of uric acid in the form of sodium urate on the articular cartilage of joints, on tendons & in the surrounding tissues.

Sex- Gout is predominantly a disease of men.

Age- It usually begins in middle life.

Causes-
(1) Primary or idiopathic- This type of gout has no cause. Most cases of gout belong to this type.
(2) Secondary- This type of gout has an underlying cause. In this type another disease like lymphoma, leukemia etc is the underlying cause of raised uric acid level in the body & the consequent result is the development of gout.

Risk factors-
(1) Diet- Diet comprising too much meat or fish increases the risk of gout as they are rich in purines.
(2) Life style factors-Excessive alcohol consumption increases the risk of gout.
(3) Certain medical conditions- Certain medical conditions like hypertension, diabetes, hyperlipidemia etc increase the risk of gout.
(4) Certain medications- Certain medications like thiazide diuretics used to treat hypertension increases the risk of gout by increasing the uric acid levels.
(5) Family history -Chance of developing gout increases if there is any family history of gout.
(6) Surgery, trauma, etc- Acute attacks of gout are provoked by surgery, trauma, etc.

Site of lesion - It is usually monoarticular & first metatarsophalangeal joint is the most common site of involvement. Ankle, Knee, wrist, fingers & elbow are other joints affected. Distal & lower extremity joints are involved more often.

Associated medical conditions- Gout may be associated with hypertension, obesity & atherosclerosis.

Pathophysiology- The biochemical abnormality in gout is hyperuricaemia resulting from overproduction of uric acid in the body or its under excretion via kidney. Uric acid is the end product of purine metabolism. It is the last step in the breakdown pathway of nucleoprotein & purines. Uric acid is completely filtered by the glomerulus of the kidney & then subsequent complete reabsorption by proximal tubules followed by secretion of its major portion by the distal tubules occurs, thus maintaining the normal uric acid level in the blood. In primary gout the major cause of the hyperuricaemia is increased urate production, but there is also impaired renal excretion. But it is to be mentioned that hyperuricaemia does not always cause manifestation of gout. When crystals of uric acid in the form of sodium urate precipitate on the articular cartilage of joints, on tendons & in the surrounding tissues, then only there is manifestation of gout.

Clinical Features- The signs & symptoms of gout are always acute & occur suddenly usually at night without any warning & consist of intense joint pain & swelling involving a single joint, most often in the feet, especially the big toe. The typical gouty joint is red, warm, swollen & exquisitely tender. Sometimes the inflammation is so gross that it may resemble cellulites. In later stages of the disease, there is presence of tophi in the ear lobules or around joints which provides a clue to the correct diagnosis.

Investigations-
(1) Routine blood test- Routine blood test may show leucocytosis & raised ESR.
(2) Analysis of joint fluid- Joint fluid from an affected joint examined under a polarizing microscope if reveals the presence of urate crystals, diagnosis is confirmed.
(3) Blood test for uric acid level estimation- Blood test reveals high uric acid levels. But it may be misleading as people with high uric acid levels may never experience gout whereas people with normal or slightly raised uric acid levels may have clinical features of gout.
(4) X-ray - X-ray is usually normal but it may show deposits of tophi & bone damage due to repeated inflammations. X-ray can also help in monitoring the effects of chronic gout on affected joints.

Differential Diagnosis- Gout may be confused with cellulites, rheumatoid arthritis, osteoarthritis, pseudogout, psoriatic arthritis, septic arthritis etc from which it has to be differentiated.

Complications- Of the various complications, the following are important:
(1) Tophi formation- If untreated, it may cause deposition of urate crystals under the skin forming nodules called tophi.
(2) Kidney stones- Urate crystals may collect in the urinary tract giving rise to kidney stones.

Treatment-

[A] General measures to be taken are-

(1) Cold compresses on painful joints.
(2) Complete rest.

[B] Homeopathic medicines to be used – There are a lot of homeopathic medicines which are used in the treatment of gout. Some of the commonly used medicines are Aconite, Ammonium Phosphoricum, Benzoicum acidum, Bryonia, Calcarea Fluorica, Colchicum, Cinchona Officinalis, Formica Rufa, Rhus toxicodendron (Rhus.tox) etc. Aconite is helpful especially when the joint is red, swollen & the inflammation is worse at night. Ammonium Phosphoricum is very useful for chronic gouty patients with nodes in joints. Benzoicum acidum is very useful for gouty deposits. Bryonia is particularly helpful when there is pain on pressure on any spot of the affected joint. Calcarea Fluorica is usually used in gouty enlargements of the joints of the fingers. Cinchona Officinalis is useful for cases of chronic gout. Colchicum works better in gout in heel & feet, especially when the great toe is affected & the inflamed joint is tender to touch or move. Formica Rufa is useful for cases of chronic gout & stiffness of joints. Rhus.tox is helpful for those who have hot, stiff & painful swelling of joints. The potency & frequency of dosage as well as duration of treatment varies with the severity of the condition & the individual along with type of gout whether it is acute or chronic. Lower potency is to be used at the beginning. If response is not satisfactory a second dose should be used. If desired effect is still not noticed, it is better to switch over to a new medicine. If the acute stage is over & the disease passes to a chronic stage, the medicine should be changed according to the demand of the prevailing condition of the disease.

Prevention-
(1) Intake of diets with fewer purines. Curtail in intake of excessive proteins.
(2) Reduction in alcohol consumption.
(3) Intake of more low-fat dairy products.
(4) Intake of more complex carbohydrates।
Prognosis - Mild attacks resolve spontaneously within 2 days, more severe attacks may last for 7-10 days. Most patients with gout will experience repeated attacks of arthritis over the years.

In short, gout is manifested by intense joint pain & swelling involving a single joint, most often in the feet& is to be treated by Aconite, Ammonium Phosphoricum, Benzoicum acidum, Bryonia, Calcarea Fluorica, Colchicum, Cinchona Officinalis, Formica Rufa, Rhus.tox etc.

But in every case, a doctor should be consulted.

Some aspects of “Carpal Tunnel syndrome” with homoepathic mode of treatment

Carpal Tunnel syndrome is an entrapment neuropathy of wrist. It is a disorder caused by compression at wrist of median nerve supplying hand, which causes tingling, numbness.
Sex- Women are more affected than men.

Age- Usually between 30 to 60 years.

Aetiology- Most cases are idiopathic. Trauma to wrist causing fracture or sprain, pregnancy, multiple myeloma, amyloidosis, rheumatoid arthritis, acromegaly or hypothyroidism all may play a role in the development of carpal Tunnel syndrome.

Risk factors-
(1) History of affection of any family member.
(2) Certain occupations.
(3) Stress.
(4) Obesity.
(5) Smoking.
(6) Oral contraceptives.
(7) Age over 40 years.

Associated medical conditions- Carpal Tunnel syndrome is sometimes associated with pregnancy, multiple myeloma, amyloidosis, rheumatoid arthritis, acromegaly or hypothyroidism.

Pathophysiology- Pressure on the median nerve due to a swelling or anything that makes the Carpal Tunnel smaller compresses the median nerve at wrist which in turn causes tingling, numbness, weakness or pain.

Clinical Features-
(1) The first symptoms to appear are usually at night during sleep & cause nocturnal tingling & pain in the hand & sometimes forearm.
(2) It may be followed by weakness of the thenar muscles.
(3) There may be wasting of abductor pollicis brevis with sensory loss of the palm & radial three & a half fingers which are supplied by the median nerve.
(4) Tinel Test - Taping on the median nerve or on the carpal tunnel if reproduces a shock or tingling in fingers is suggestive of Carpal Tunnel syndrome & Tinel Test is said to be positive.
(5) Phalen test – Flexion of wrist causes compression of median nerve in the tunnel with the result of paresthesia in the median nerve distribution, thus reproducing the patient’s symptoms.

Investigations- The diagnosis of carpal Tunnel syndrome is based primarily on symptoms & clinical findings. X-rays may be advised which would help in detecting any fracture in the wrist that may be the cause of carpal Tunnel syndrome. MRI can also be done for visualizing injury to median nerve. However, the most important diagnostic test for confirmation of the disease is median nerve conduction study which of course has some limitations because a small percentage of patients may have negative result in spite of features suggestive of carpal Tunnel syndrome while a small percentage of asymptomatic individuals have positive results. Besides these, ultrasound imaging, electromyography may also be done.

Differential Diagnosis- Carpal Tunnel syndrome may be confused with nerve compression caused by a cervical disk herniation, thoracic outlet structures. Pain due to osteoarthritis of 1st carpal-metacarpal joint may also simulate that due to carpal Tunnel syndrome.

Treatment-
[A] General measures to be taken are-
(1) Splinting or bracing.
(2) Modification of activity.
(3) Occupational therapy.
(4) Physiotherapy.

[B] Homeopathic medicines to be used – There are a lot of homeopathic medicines which can be used in the treatment of Carpal Tunnel syndrome. Causticum, Lycopodium, Apis, Calcerea carb, Ruta Graveolens (Ruta), Rhus toxicodendron (Rhus tox), Arnica etc can be used according to the presenting clinical features. Ruta may be used when there is pain & stiffness in wrists & hands, Causticum for numbness & loss of sensation in hands, Apis for numbness of hands & tips of fingers. Arnica is usually used when there is flare-up of inflammation or new injury caused by repetitive use of fingers & wrists. Rhus tox is useful when there are stiffness & pain which get worse on initial motion but improve as movement continues. Besides these, Lycopodium may be used if tingling & numbness is confined to the radial three & a half fingers with or without wrist swelling. Calcerea carb may also be used for tingling & numbness & swelling in wrist & the radial three & half fingers. The potency & frequency of dosage as well as duration of treatment varies with the severity of the condition & the individual. Lower potency is to be used at the beginning. If response is not satisfactory a second dose should be used. If desired effect is still not noticed, it is better to switch over to a new medicine.

Prevention-
(1) Reduction of obesity.
(2) Immediate treatment of any disease which may cause carpal Tunnel syndrome.
(3) Regular breaks from repeated hand movements to allow hands & wrists to take a rest.

Prognosis- Carpal Tunnel syndrome is usually not grave. With treatment pain subsides & there is usually no lasting damage to hand or wrist. When the condition occurs in pregnancy due to fluid retention it usually requires no treatment as it is self-limiting.

In short, carpal tunnel syndrome is manifested by tingling, numbness, weakness or pain in hand due to compression of the median nerve at wrist & is to be treated by Rhus tox, Ruta, Arnica, Causticum etc.

But in every case, a doctor should be consulted.

Some aspects of “Golfer’s elbow” with homoepathic mode of treatment

Also referred to as medial tennis elbow, Golfer’s elbow is a tendinopathy of the insertion of the flexors of the fingers of the hand & the pronators.
Epitrochleitis or Golfer’s elbow is very similar to lateral epicondylitis or tennis elbow but occurs on the medial side of the elbow, where the pronator teres & the flexors of the wrist & fingers originate. Tensing of these muscles by resisted wrist & finger flexion in pronation will provoke the pain.

Sex- Golfer elbow is most common in men.

Age- 20 – 50 years of age but the condition can affect anyone who repetitively stresses the wrist or the fingers.

Risk factors-
(1) Repeated or forceful movements of the fingers, wrist & forearm which causes repetitive strain on forearm flexors.
(2) Acute trauma may also play a role.

Pathophysiology- The flexor muscles of hand, wrist & forearm on excessive strain or over-use, may become irritated, inflamed & swollen. This causes pain & tenderness at the medial epicondyle of humerus. If not arrested at this point & allowed to progress, the tendon develops small tears in it at its attachment to the humerus.

Clinical Features-
(1) The most common symptom is pain & tenderness on inner side of elbow. The pain may occasionally extend along inner side of forearm. Onset of pain is usually gradual & aggravated by using the affected muscles while grasping objects or shaking hands. Tenderness is often less well localized than in tennis elbow.
(2) There may be a feeling of stiffness of elbow.
(3) Weakness of hands & wrists may also be there.
(4) Numbness or tingling sensation radiating into usaully ring & little fingers may be present.
(5) There will be pain on resisted forearm pronation with elbow extended or pain on resisted wrist flexion & these are the tests for clinical diagnosis.

Investigations- Golfer’s elbow is usually diagnosed clinically. X-ray of elbow is often done to rule out arthritis. MRI may be advocated if clinical diagnosis is difficult to be confirmed.

Differential Diagnosis- Golfer’s elbow is usually to be differentiated from Olecranon bursitis, Elbow arthritis, Carpal tunnel syndrome.

Treatment- It is the same as for tennis elbow but the treatment is even less satisfactory.
[A] General measures to be taken are-
(1) Rest.
(2) Restriction or total stoppage of activities causing pain.
(3) Elbow braces.
(4) Stretching exercises for flexor muscles which should be started after the disappearance of the symptoms of Golfer elbow. If there is any pain during or after the exercises, it should be stopped immediately.
(5) Physiotherapy.

[B] Homeopathic medicines to be used – Homeopathy may be used effectively in the treatment of Golfer elbow. If it is supposed to be due to overuse, Bryonia should be tried. Ruta Graveolens (Ruta) & Rhus toxicodendron (Rhus tox) are the medicines most commonly used. The potency & frequency of dosage as well as duration of treatment varies with the severity of the condition & the individual. Besides these, if it is supposed to be due to any previous injury, Arnica can be very effectively used. On the other hand, if it is supposed to be due to overuse, Bryonia may be tried.

Prevention-
(1) Modification of activities or particular techniques that lead to the development of this overuse injury.
(2) Guidance of a coach for sporting activities may often be helpful.

Prognosis- Golfer elbow is usually a self-limited problem which is quite unlikely to cause any long-term health hazard. With athletes a change in technique often resolves the problem. Life style modification is to be considered if Golfer elbow does not resolve or if it recurs.

In short, Golfer’s elbow is manifested by pain & tenderness on the medial side of the elbow & is to be treated by Rhus tox, Ruta, Arnica etc.

But in every case, a doctor should be consulted.