Arthritis and rheumatism are among the commonest forms of chronic disease especially amongst the aging population. Although arthritis means disease of the joints and rheumatism is disease of the soft connective tissues which support and move the joints, the distinction is unclear since many of these conditions affect both the joints and connective tissues.
“acute or chronic inflammation of a joint, often accompanied by pain and structural changes and having diverse causes, as infection, crystal deposition, or injury.’
Dictionary reference online: http://dictionary.reference.com/browse/arthritis
Scope of this paper
In this paper I will explain the nature of the disease, its conventional management and then move to the homeopathic perspective of diagnosis analysis and management. Because of its close association I will include rheumatism in this paper.
CONVENTIONAL PERSPECTIVE AND MANAGEMENT
Pathology and aetiology of Arthritis
Many different ways of classifying arthritis
- Involvement of joints
- Monoarthritis and polyarthritis
- Monoarthritis including Pyogenic arthritis
- Secondary osteoarthritis
- Rheumatoid arthrits
- Primary osteoarthritis
- Monoarthritis including Pyogenic arthritis
- Monoarthritis and polyarthritis
- Juvenile chronic polyarthritis
- Cause of arthritis
- Degenerative as in osteoarthritis
- Metabolic as in gout
- Autoimmine as in rheumatoid
- Infective as in Tubercular
- Secondary as in psoriasi
- Seropositive as in rheumatoid arthritis, Still’s disease.
- Seronegative spondyloathropathies
Focusing on the commonest forms of arthritis we have:
- Degenerative arthritis of which the most common is osteoarthritis.
Osteoarthritis is a very common condition and is probably the most common chronic disease and typically joints affected are the weight bearing joints and well as the spinal column. Big joints are affected and it involves degenerative processes involving the wear and tear of the joints. In cases of injuries, the degenerative changes can arise very much later in life. In osteoarthritis there is wearing out of the cartilage part of the joint and the joint becomes stiff and painful, and may creak as it moves. When the cartilage gets worn out, the bones on either side of the joint reacts by forming small bony outgrowths called osteophytes. Spondylosis is the name given to osteoarthritis affecting the spine. In such cases the main problem is degeneration of the disks which separate the vertebrae.
- Inflammatory arthritis is the other big group and the most common of it is rheumatoid arthritis, gout and soft tissue rheumatism. Rheumatoid arthritis tends to come on at an earlier age than osteoarthritis, which may be around thirty years to fifty years old and is more aggressive and has a more rapidly deteriorating course. Serious disabilities may occur within ten years in some individuals. Although it particularly affects the small joints, especially of the hands and feet, causing a typical hand deformity where the fingers slant sideways, it can also affect almost any joint in the body, and also cause nodules under the skin and eye problems. Besides rheumatoid arthritis, there are many other forms of inflammatory arthritis, some of them associated with infections and metabolic disorders such as gout in which uric acid is deposited in the joints affected, starting an inflammatory process. In conventional medicine, the cause in unknown except that it tends to occur as an inherited weakness.
Soft tissue rheumatism affects the soft tissues around the joints and some of the conditions are tennis elbow, housemaid’s knees as well as frozen shoulder. The most well known soft tissue rheumatism is fibromyalgia which affects groups of muscles and has certain pain points throughout the muscles. It is thought to be associated with chronic fatigue and may occur with other health issues such as irritable bowel and migraine. Fibromyalgia is also associated with poor sleep and a multitude of emotional consequences.
Diagnosis of arthritis and rheumatism
Diagnosis is made by medical and family history and an assessment of the level of pain and range of movement and areas of stiffness which include the duration and times of the pains. This is to identify the types of arthritis present although in conventional management it does not really change the management very much because the management consists only of anti- inflammatory and pain relieving drugs with their fair share of side effects. These drugs do not stop the progress of the disease. Imaging Tests are also carried out, the most common being X ray but ultrasound and MRI can also be done. The image will be read for structural changes in the joint, signs of joint erosions, cartilage loss, soft tissue tears, inflammation, location and amount of fluid, and presence of loose tissue fragments.
Relevant lab tests can be done to check for the levels of inflammation, serological tests, presence of antibodies and the state of the liver and kidney and the full blood picture which can demonstrate the inflammation via the raised ESR and the presence of infection by the white blood cell count. Renal and kidney profiles are important because of the drugs used in conventional medicine which may compromise these organs. For gout the uric acid level can be obtained.
As mentioned before, in conventional medicine, management is by drugs which suppress inflammation and pain.
Depending on the type of arthritis, the drugs used are:
- Non steroidal anti inflammatory drugs
- Glucocorticoids – for example prednisolone
- Biological response modulators –These are substances that modify the body’s response to infection and disease. Examples are: monoclonal antibodies, interferon, interleukin-2 (IL-2), and several types of colony- stimulating factors (CSF, GM-CSF, G-CSF).
- Disease Modifying Anti-rheumatic drugs. These slow down the destructive processes in inflammatory arthritis. Examples are Hydroxychloroquine, Sulfasalazine, gold salts and cytotoxic drugs.
- Specific arthritis like gout are treated with uric acid lowering drugs
- Other drugs to deal with depression and spasms are also used.
Supplements may be recommended when bone loss like osteoporosis is involved. Lifestyle exercises, joint sparing techniques and dietary changes may be recommended and physiotherapy may be applied. In advanced cases with severe loss of function, surgery may be recommended and in some cases of arthritis of the knees, knee replacement can be recommended.
HOMEOPATHIC PERSPECTIVE AND MANAGEMENT
In a homeopathic approach, a person with a condition is treated individually and while the disease name and pathological diagnosis may be the same for a number of people, they differ in their individuality and it is in this individuality that the approach and management is tailored.
In the homeopathic approach a case of arthritis could be either psoric, sycotic or syphilitis, as well as tubercular depending on the presenting symptoms and the constitution of the patient.
Homeopathic Case taking in arthritis
Questions to ask in the case taking will be:
- Who is the person with arthritis?
This is important as regards age sex, body build and occupation as well as the lifestyle including food and activities. Family history and relationships, job and occupation are all important. As an example, in a young man who works as a manual laborer and takes a lot of carbohydrates and sweet drinks who started to have knee pains, it would be for a different reason than a lady of 50 who works in an office and is particular about her food and takes balanced meals as well as swims regularly. In the former case, the arthritis could be psoric in nature and in the latter case there is a possibility of it being sycotic.
- What started the arthritis or the question: When did it start and what was happening at that time, is particularly useful in ascertaining a possible trigger for the arthritis. This could be an emotionally traumatic event or a physical trauma as well as an infectious disease.
- The constitution of the person with arthritis. This would give information about the type of arthritis that the person has and would indicate the group of remedies and adjuvant measures needed.
- Local symptoms related to the arthritis including which joints affected need to be recorded and this would include modalities of location, sensation, time of occurrence, ameliorations and aggravation factors, periodicity if any and concomitant symptoms.
- Mental generals and physical generals are an important part of individualising the case.
- Family history would point to the susceptibilities and the inherited miasms of the patient.
- Other symptoms of the patient both related and unrelated to the arthritis have to be recorded as well. This will be useful to derive the essential drug picture of the patient.
Homeopathic drug treatment of arthritis
The treatment approach will depend on the degree and type of arthritis, whether it is in the curable state or the incurable state of arthritis.
In any type of arthritis, when the disease is recurring but in between the attacks the joint is normal and there are no pathological changes, the approach to take would be to prescribe based on essential totality. Such cases are curable with the right approach and the right homeopathic treatment.
The remedy prescribed would be a constitutional remedy given in single doses at a potency of 1M and repeated monthly or at any suitable interval according to the response of the patient to the remedy.
In cases where the pathology has advanced and there are organic changes which render the disease incurable, then the remedies given will be based on the local pathology ie. pathological prescribing. The remedies will be prescribed in low potencies of between 6c or 12 c and frequently repeated as needed.
For cases that are one sided where modalities cannot be elicited then a miasmatic remedy can be selected based on family history and past medical history. A single dose of the selected nosode and a waiting period of up to six weeks may bring up features of the case which can then lead to a prescription of the essential totality.
Remedies that control the pain can be given as and when needed. While each of the remedies is most useful for certain types of arthritis, when symptoms match, any remedy can be used for any type of arthritis.
In brief, among the common remedies that control pain are as below:
Bryonia Alba. – Pain with inflammation which, is aggravated by movement and relieved by moderate pressure and rest.
Ledum pal. – Excellent remedy for gout and rheumatism which is of ascending nature, better by cold application.
Rhus Tox. – Pain aggravated by first movement, damp weather and better by continuous motion.
Colchicum – pain worse by motion touch or mental effort, better by warmth and rest.
Kalmia latifolia – descending type of pain, pain with palpitation of heart and slow pulse
Guaiacum. – Gouty abscesses of joints, pain relieved by cold bath and cold application.
Benzoic acid – gouty concretions of joints, knee pain due to abnormal deposition of uric acid
Hypericum. – A remarkable remedy for rheumatoid arthritis that has outstanding action over nerve pain.
For cases of rheumatoid arthritis, the following remedies have been found useful:
Rhus tox is a superb remedy for any kind of arthritis where there is the characteristic symptom of aggravation by cold wet weather, or by getting wet and aggravation on initial movement and ameliorated by continued movement. In a case needing Rhus tox, the pains at night cause the patient to have to change positions regularly in order to find relief.
Bryonia for acute painful joints aggravated by movement in acute pains of rheumatoid arthritis when the pains are worse by slightest motion or touch. The joints are acutely inflamed and there is anguish and agony on account of pain. The pains are associated with swelling of the joints. In acute exacerbations when there is fever, Bryonia can be prescribed. There may be whitish coating on the tongue and the mouth and the throat are extremely dry. Fever may be associated with thirst.
Pulstatilla is indicated in rheumatoid arthritis when the pains keep changing their locations. The pains are worse in the night, on rest and in warm closed rooms. However, the pains are better in open air and by warm applications.
Salicylic Acid for pains with fever. Salicylic acid may be prescribed when the involvement is primarily in the upper extremities. There may be profuse swelling and redness in the affected joints. Most often, the pains are associated with high to very high fever. The pains are pricking type and may be worse by exposure to cold and better by warmth in general.
Phytolacca Indicated in cases of RA which are worse in the morning hours Along with the joint pains, there may be a sore, bruised feeling in the whole body. There may be stiffness in the shoulders, knees and ankles. The feet are swollen and walking is restricted on account of acute pain. Associated symptoms are weakness and fatigue. There is pain in the heels which feels better by raising the leg.
Gelsemium may be indicated in acute pains which are of burning nature and are worse by heat. There is extreme weakness with lethargy. Gelsemium may be given in cases which become worse during change of seasons and in damp surroundings. The joints are swollen and there may be extreme weakness in the surrounding muscles. During an acute attack, there is marked trembling of all the limbs. Gelsemium may be given when there is a sore, bruised feeling in the back muscles as well.
In Cases of gouty arthritis, several remedies are known to improve the local pathology and reduce the uric acid levels in the blood. Among the remedies are:
Colchicum autumnale fits chronic cases of gouty arthritis where the pain is in the big toe and the pain is intense when stubbing the toe. There may be inflammation in the affected joint and pains are worse in the evening and at night. Warm weather aggravates the pains.
Benzoic acid is indicated when there is offensive urine and the color of the urine may be darker than normal. While there may be pain in the big toe which is tearing in nature, the knees may also be affected and swollen. Cracking is present around the joints and patient is worse in the open air and by uncovering the affected joints.
Ledum Palustre is for pains that travel from below upwards, for example, starting in the feet and travelling to the knees. Small joints are more commonly affected. Warmth aggravates and cold applications ameliorate. The ball of the great toe may be swollen as well as the ankles.
Antim Crud is indicated for gout with gastric symptoms. Appetite is much increased an over indulgence in food which raise uric acid may contribute to the problem. The pains are worse by heat and cold bathing. The person does not like to be outdoors in sunny weather. Irritability as well as thick white coat on the tongue are characteristic.
Sabina is for gout in females where there is a presence of uterine symptoms. Pains are shooting in nature and aggravated in a warm room. There is inflammation in affected joints
In cases of osteoarthritis, the degenerative pathology has caused damage to the joint and there may be the presence of osteophytes. While early cases may be curable, this type of arthritis is amenable to palliation for established cases and maybe even for heavily drugged cases which tend to be the most difficult to manage. In such cases, low potencies and mother tinctures are useful and it is only when the symptoms are much ameliorated and when there are signs of elimination and discharge that the case can be treated in a more comprehensive manner by selecting the indicated essential totality. Elimination may be seen in the form of skin symptoms, mucous formation or any discharges from the body.
Remedies chosen may be from those described earlier including Ledum, Rhus Tox and Bryonia and these other remedies as below.
Formic Acid and Formica Rufa is indicated for inflamed and painful joints worse on moving, by cold and before a storm and is better by pressure.
Lithium Carb is for when the pain is stitching or stabbing and burning. Temporary relief is by cold applications and not by rest or moving. Pain is severe enough for the patient to scream in pain. There may be backache with great weakenss and profuse sweating. Pains will move to other joints when affected joint is covered. Aggravation is by uncovering and by eating.
Sticta Pulmonaria is for pain in the shoulder, wrist joint ankle and knee joints. It is for joints which have swelling due to fluid and may reduce the fluids.
Berberis Vulgaris is for pain in the heels and is useful in cases with renal issues and a stitching backache.
Chelidonium Majus is for rheumatism with edema heat and tenderness with stiffness, constipation with whitish stools which may indicate gall bladder pathology. Pain aggravated by movement and relieved temporarily by bathing with hot water.
Ferrum picricum is useful in pains which are increased by walking .
Lactic acid is useful for arthritis associated with Diabetes Mellitus
Hypericum when there is associated nerve pain as in ostearthritis affecting the spine.
In one sided cases, the indicated nosode or main remedy associated with the miasm discovered can be prescribed at the start of the case to bring out the symptoms of the case which have been suppressed. Among the nosodes that may be called for are, medorrhinum, tuberculinum, syphilinum and psorinum carefully chosen based on the prominent symptoms of the patient and the known family history as well as the past history. In some cases, a miasmatic homeopathic remedy may be chosen for example, Sulphur in cases which do not have characteristic symptoms to prescribe on. It could be given in 200c as a single dose and with a period of waiting without remedies to observe the response to the remedy before re-prescribing.
Emotional aspects of Arthritis cases
While it has been mentioned that in cases which are incurable and a lot of pathology is present the remedies chosen have to be based on pathological prescribing, when there are very prominent mental symptoms with strong implications on the anxiety and behaviour of the patient, a remedy based on the mental generals may be chosen. My own preference is not to go too high, and the potency I usually use in 200 c. The number of doses depends on the response of the patient to the remedy. One dose or three doses depending on the response of the patient to the remedy.
The remedies for emotional aspects include:
Staphisagria, Arsenicum Album, Ignatia, Chamomilla, Nux Vomica, Natrum Mur and Sepia. There are indeed very many other remedies which can be selected based on the presenting symptoms. Emotional aspects can also be addressed by counselling, coaching and suggestions to eliminate the causation of the patient’s emotional state.
Adjuvant measures in all cases of Arthritis
It cannot be over emphasized that homeopathy is a holistic approach to healing and the lifestyle and food taken by the patient has to be addressed. Some of these factors may be the maintaining cases of the arthritis and have to be removed. It is well known that a diet high in carbohydrates and sweets can induce an acidic state of the tissues which can trigger many of the miasms already present in the patient. This is also true of a diet high in animal proteins. Among important nutrients are minerals and essential fatty acids and today’s diet provides too much of spoiled transfats which disturb the balance in the body. A high omega 6 to omega 3 ratio triggers inflammation in the body. (5)
The gut health is also to be looked into and a healthy gut microbiome can be promoted by making sure there is enough dietary fibre and fermented foods in the diet. Research into this has found a link between rheumatoid arthritis and gut health. (9)
Toxins in food and the environment should be minimised and for this there are investigations that can be done to identify them, and then one takes necessary measures to remove them.
Exercise and activities have to be tailored to suit the patient’s constitution, personality and the limitations caused by the arthritis.
Physiotherapy and hydrotherapy, hot and cold foments as indicated by each case as well as massage are adjuvant measures that can relieve the patient and accelerate healing.
- A 20-year-old girl presents with acute pain in her right ankle. On examination the ankle was swollen and painful. She started having the swelling two weeks ago after a bout of fever and she had been to see the doctor and was given NSAIDs. The pain did not resolve and she was admitted for investigations.
She was discharged a week later and when seen, was still having pain and swelling of the ankle. Apparently the investigations did not reveal any abnormalities in her blood picture and serological tests were negative.
The pain was aggravated by the least motion and she was very thirsty for large amounts of water. She was constantly talking about things she had to be doing and classes that she had missed due to her illness and was very much agitated over this. There were no other symptoms. She was given 5 doses of Bryonia 30c to be taken daily unless there was a response in which case she was to stop the remedy and wait. She was told that the response might mean a fever or rashes or any signs of discharge. She came back a week later with her ankle returning to normal. After the third dose, she had a red rash all over her body which subsided by itself after one day. As per instructions, she did not seek any treatment. This case demonstrates a psoric form of arthritis in which a remedy was given that resolved the problem without any further recurrence.
- A lady of 35 presented with multiple joint pain. Pains were aggravated on first motion but ameliorated on continued motion, aggravated at night and she had to move her body to relieve the pain. It is also aggravated after she gets wet when caught in the rain. 7 months previously she had caught Chikungunya and at this time, she was treated with NSAID and later, when the pains kept persisting, she was put on steroids. She was well for about 2 months and then started having multiple joint pains recurrently every month. Every time they came, the arthritis was resolved with NSAIDS. Lately, in the past month, the pains did not resolve with NSAIDS and the joints affected, which were both her knees and ankles, did not go away. In fact the left knee was swollen for the past month. This was her condition when first seen. Mentally, by nature she was a superstitious woman who felt that she had been cursed and therefore developed this condition. Her father had suffered from a gouty arthritis and her sister had fibroid uterus. When prescribing, it was taken into consideration that her disease had evolved and had steadily become worse and it was only recently that the condition persisted despite allopathic treatment. Therefore, this is a case that is moving from a psoric to psoro-sycotic. The remedy chosen, based on essential totality was Rhus Tox 200c. It was given for 5 doses to be taken every other day and stopped as soon as there were any signs of response.
She presented a month later with pain only in her ankles. After the 3rd dose, the left knee was greatly aggravated and she was bedridden for two days. This was followed by fever and then multiple joint pains, even in the elbows. She reported that it resembled the Chikungunya she had earlier. This time she did not take anything for it. After a week, the arthritis was now only present in her ankles, but now it was static. Another dose of Rhus tox was given, this time in 1 M. In the third follow up a month later, there was only slight pain in the ankles on movement and rest ameliorated it. Earlier she had to keep moving the joints even when sleeping, Placebo was given and the case resolved completely on the next follow up a month later without any further problems. Follow up was set to 3 months, and a miasmatic remedy may be given in the future to address her family history.
- A man of 50 presented with a pain in his right big toe accompanied by swelling. He has had several recurrences of this problem and had a uric acid level of 9 mg/dl. He was a long term diabetic with protein in the urine although his creatinine levels were within normal limits. He was on metformin 500 mg tds for his diabetes. His blood pressure was also elevated and for this he was taking micardis 80mg daily. On the day he presented his BP was 140/85 and his fasting blood sugar was 7 mmol/l. The pain in the toe was greatly increased because he had stubbed his toe against the bed. Pain was much aggravated in the evenings and he had been out in the sun the day before the toe became painful. Colchicum autumnale was prescribed in a low dose of 6 c daily. When he returned a week later, the swelling had subsided and his uric acid level had come down to 7 mg/dl. His prescription was continued for another two weeks. He reported having diarrhea after the third day on Colchicum autumnale and this elimination symptom was taken as a good sign and response to treatment.
On, follow up, the uric acid level had fallen to 6 mg/dl. On this visit, the case was retaken and it was discovered that his father had suffered from gout as well and his mother had cancer of the breast and had died from it. Based on this history, a single dose of Carcinosin 200 was given.
The patient presented again 6 weeks after this. At this time, he had developed some symptoms which he had suffered from when he was 35 years of age. He now perspired rather profusely and prior to this he did not sweat very much. His manner had become rather open and he was quite talkative. Other than that, an old fear had returned. The previous day, there was a thunderstorm and he found that he had become rather anxious during the storm. He also wanted his drinks cold and that made him feel better. Based on these symptoms, phosphorus 1M was prescribed. He was also given mother tincture of szygium jambolanum 10 drops two times a day for his diabetes mellitus. Since szygium jambolanum also has a positive effect on dyslipedemia it could possibly address his hypertension as well. No other mother tincture was given for his hypertension at this point in the treatment. He was still on his drugs and was told to be aware of signs of hypoglycemia and the plan was to taper down the dose of his drugs.
This case demonstrates
- Pathological prescribing when the pathology presented as a one sided case.
- Miasmatic prescribing when the acute exacerbation had subsided and
- essential totality prescribing when the case had reverted to a case with numerous symptoms that indicated a recognisable polychrest constitutional remedy.
- Since the Diabetes Mellitus was of long standing, a mother tincture prescription was given. This is again pathological prescribing.