Some aspects of “ Rheumatoid Arthritis ” with homoepathic mode of treatment

Rheumatoid arthritis (RA) is a chronic symmetrical polyarthritis affecting mainly the peripheral small joints associated with some constitutional symptoms.

Age- Though it is seen in some children, it has increasing prevalence with increasing age up to the seventh decade and most often it starts between the ages of 30 & 40 years.

Sex-It is two or three times more common in women than men. In young adults with RA, females have a worse prognosis than males.

Cause-The cause of the disease remains unknown. An infectious agent, perhaps viral, is suspected to be the initiating factor. The process by which an infectious agent might cause chronic inflammatory arthritis with a characteristic distribution also remains unknown. Many immunological disturbances are noted in RA & it is considered to be an autoimmune disease.
Risk factors-
(1) There is an increased incidence in those with a family history of the disease.
(2) A genetic predisposition may also be a factor. An association with HLA-DR4 has been noted in many populations, but not all. In some populations, HLA-DR1 is found in the majority of HLA-DR4 negative patients particularly in Indians & Israelis.
(3) Environmental factors are also supposed to play a role in the etiology of the disease.

(4) Smoking may also act as a risk factor for RA in persons expressing the susceptibility allele.

Pathology- Rheumatoid Arthritis is a disease of the synovium which passes through an inflammatory process followed by proliferation. The chronic inflammatory reaction causes infiltration of the synovium with lymphocytes, plasma cells & macrophages. The synovium then undergoes proliferation with growth over the surface of the cartilage.

Onset- Usually gradual, sometimes acute, especially in the elderly when it is sometimes called ‘explosive RA’.

Clinical features-

(1) Joint pain-The pain is worst on waking in the morning which may improve with activity. Pain at night may cause a disturbed sleep.
(2) Morning stiffness-It often lasts for several hours & with progress of the disease becomes very prominent.
(3) Swelling – Gradually swelling of the small joints of fingers & toes, commonly the former is seen due to soft tissue swelling caused by effusion or synovial proliferation. The swelling starts with one joint, then another joint is involved and ultimately systemic swelling of joints is seen. Bigger joints like wrist, elbow & ankle are usually seen to be involved but shoulder, hip & spinal joints are rarely involved.
(4) Warmth-The joints are hot to feel.
(5) Tenderness- The joints are tender on pressure or movement.
(6) Formation of nodules- Presence of subcutaneous nodules is found almost invariably in individuals with circulating rheumatoid factor. They vary in size and consistency and are rarely symptomatic. Though they can develop anywhere, they are mostly found on periarticular structures, extensor surfaces & over areas subjected to mechanical pressure. Common sites of development are olecranon bursa, proximal ulna, Achilles tendon, and the occiput.
(7) Limitation of movement- Movement is restricted with muscle wasting around the affected joints.
(8) Deformities- Deformities may occur in the advanced stage of the disease.

Investigations- No tests are specific for diagnosing RA.

(1) Rheumatoid factors- Rheumatoid factors which are autoantibodies may be found in more than two-thirds of adults with the disease. But as rheumatoid factor is also found in a small percentage of normal population, its presence is not specific for RA.
(2) Routine Blood Tests- Anaemia is a routine finding in almost all cases of rheumatoid arthritis & is usually normochromic, normocytic in nature. It is proportional to the activity of the inflammatory process. There is thrombocytosis which correlates with the disease activity. The white blood cell count is usually normal, but a mild leukocytosis may be present. The erythrocyte sedimentation rate (ESR) and C-reactive protein level are elevated and usually both the elevations correlate with disease activity and the likelihood of progressive joint damage. Serum alkaline phosphatase may also be raised in some cases of active rheumatoid arthritis.

(3) X-ray- Early in the disease, radiographic evaluations of the affected joints are usually not helpful in establishing a diagnosis. Juxtaarticular osteopenia is the first radiographic finding to be seen. Loss of joint space indicating thinning of the cartilage may be there after the disease process has reached a certain level. The characteristic lesion is that of an erosion that appears as a mouse-bite on the surface of the affected bone. The primary value of radiography is to determine the extent of cartilage destruction and bone erosion produced by the disease as well as the response of the disease to the treatment.

Differential diagnosis-Rheumatoid arthritis is to be differentiated from osteoarthritis, psoriatic arthritis, ankylosing spondylitis, septic arthritis, sarcoidosis, systemic lupus erythematosus (SLE) etc

Complications-
(1) Vascular System-Rheumatoid vasculitis may be seen in patients with severe RA and high titers of circulating rheumatoid factor, usually in limited forms & especially in the whites. Widespread vasculitis is usually very rare.
(2) Respiratory System- RA especially in men may sometimes cause pleural disease, interstitial fibrosis, pleuropulmonary nodules, pneumonitis etc.
(3) Nervous System- RA usually has no direct action on the central nervous system but vasculitis in turn can cause peripheral neuropathy & mononeuritis multiplex. Moreover, nerve entrapment secondary to proliferative synovitis or joint deformities may produce neuropathies of median, ulnar, radial or anterior tibial nerves.
(4) Eye- Episcleritis & scleritis may be seen in some patients with long standing RA with nodules.

Treatment- Management is directed towards relief of pain, control of synovitis and prevention & / or treatment of associated involvement of other ओर्गंस.

[A] Physical therapy- Physical therapy such as heat & ultrasound is used to decrease joint stiffness & relieve pain. An exercise programme should be fixed for preserving the functional abilities of the patient giving special stress to put all joints through their full arc of motion to maintain this range. Special importance should be given on aerobic exercise.
Relaxation techniques should be practised.

[B] Occupational therapy- Occupational therapy, after proper evaluation of the patient, aims in engaging the patient in modified techniques for performing activities of daily living.

[C] Homeopathic therapy- As no medicine is ideal, it is important to assess the patient’s response so that the most effective regimen is adopted. After proper evaluation, the suitable one is selected from the following homeopathic medicines-
(1) Arnica- This remedy may be used in patients of RA with chronic arthritis associated with a feeling of bruising & soreness, the pain being increased on movement.
(2) Bryonia- This remedy may be used in patients of RA for stiffness & inflammation with tearing or throbbing pain, the pain being increased on movement.
(3) Ledum palustre- This remedy may be used in patients of RA with initial involvement of lower joints which then gradually extends to upper ones
(4) Pulsatilla- This remedy may be used in patients of RA with flare-ups from one place to another.
(5) Calcarea carbonica (Calc.carb)- This remedy may be used in patients of RA with involvement mainly of the knees & hands, especially where nodes have already developed around the joints.
(6) Causticum- This remedy may be used in patients of RA with involvement mainly of the hands & fingers, especially with muscle weakness & contractures.
(7) Calcarea fluorica- This remedy may be used in patients of RA with swollen & hard joints, especially where nodes or deformities have already developed.
(8) Rhus toxicodendron (Rhus.tox)- Rhus.tox may be advised for patients of RA with pain & stiffness which is worse in the morning & improves with continued movement.
(9) Ruta graveolens (Ruta)- Ruta may be advised for patients of RA with deep affection or damage of tendons & capsules of the joints.
The medicine of choice & the potency & frequency of dosage as well as duration of treatment varies with the demand of the symptoms along with severity of the condition & the type of the individual। Lower potency is to be used at the beginning। A single dose is to be used first। If there is response, no second dose should be taken until there is cessation of further improvement। But if there is no response after the first dose a second dose should be taken after a gap of 2 or 3 days. If desired effect is still not noticed, it is better to switch over to a new medicine. Sometimes multiple dosages of the medicine of choice are to be used a day, the frequency is then gradually reduced according to the improvement of the condition, but have to be continued a few days even after the desired effect.

Besides the above mentioned medicines, Ferrum Metallicum may be used to combat the anemia that occurs in रा

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Prevention-
(1) Intake of a low-protein, high carbohydrate diet with minimization of foods of animal origin.
(2) Elimination of milk & milk products from diet.
(3) Avoidance of polyunsaturated vegetable oils.
(4) Increased intake of omega-3 fatty acids.
(5) Reduction in intake of coffee & tobacco.

Prognosis- Despite full treatment & all the precautions to be taken, a few percentages of patients become severely disabled. The more the number of joints is involved, the poorer the prognosis is. Women & whites have a relatively poorer prognosis. Smoking has a detrimental effect on the course of the disease. Life expectancy may be decreased in some individuals due to associated heart disease, infection etc.

In short, Rheumatoid Arthritis is manifested by pain, stiffness & swelling of the small joints of fingers & toes & is to be treated by Arnica, Bryonia, Calcarea carbonica, Calcarea Fluorica, Causticum, Rhus।tox, Ruta, Ledum, Pulsatilla 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.