Disease Index Homeopathy Papers

Homeopathic Remedies for Rheumatism

Written by Robert Medhurst

Homeopathic remedies and homeopathy treatment for Rheumatism. As the weather starts to cool down, many of us will be faced with patients experiencing aggravations of rheumatics. Here are some reminders of remedies that you may find useful for clients suffering from rheumatic symptoms that’s worse in cold weather.

As the weather starts to cool down a bit, many of us will be faced with patients experiencing aggravations of rheumatism. Here are some reminders of remedies that you may find useful for clients suffering from rheumatism that’s worse in cold weather.

Remedy Characteristics
Arnica Sufferer feels bruised or beaten, rheumatic symptoms begin low and work their way up the body. Symptoms are worse for touch, motion and rest
Benzoic acid Pains change position suddenly and are better for heat or profuse urination. Symptoms are worse for motion and wine.
Calc carb Rheumatic symptoms often appear after exposure to wet weather and extremities feel cold and weak. Symptoms are better for constant walking and worse from standing, rest or lying down.
Calc phos Symptoms involve feelings of stiffness, numbness and coldness.
Causticum Stiffness and contraction of muscles with weakness, tearing pains and trembling may indicate the need for Causticum. Symptoms are worse for cold, dry weather and better for wet, damp weather.
Cimicifuga Uneasiness, aching and restlessness of the limbs, with muscular aching, better for rest and worse for motion, at night and as evening approaches
Dulcamara Rheumatic symptoms alternating with diarrhoea, limbs feel icy cold. Symptoms are better at night and for motion.
Formica Rheumatic problems with restlessness that appear suddenly and are improved after midnight and after rubbing.
Kali bic Pain that moves quickly from one place to another, swelling, stiffness and cracking of joints; better for motion and pressure and worse in the morning.
Phytolacca Shooting, electric shock-like rheumatic pains that shift rapidly with hard shiny swelling of the joints that are worse at night and for rain or motion.
Rhus tox Hot, painful swelling in joints with stiffness and tearing pain in connective tissues, better for motion and worse for rest.
Ruta Stiffness and pain in the lower back, hands and wrists, worse from exertion.
Salicylic acid Swelling and pain in joints (especially the knees) that shift in location, worse at night and worse for touch or movement.

About the author

Robert Medhurst

Robert Medhurst BNat DHom DBM DRM DNutr is an Australian Naturopath & Homeopath with 40 years of clinical experience. He has written many articles and lectured on homeopathy throughout Australia and the U.S. Robert previously set up and operated 5 natural therapies practices in Sydney and Adelaide and was involved in teaching and medical research. He was formerly the Expert Advisor on Homeopathy to the Federal Government of Australia, Dept. of Health & Ageing. He specialises in homeopathy and is the author of The Business of Healing, the definitive guide for clinical practice establishment and management, as well as The Concordant Clinical Homeopathic Repertory. For more information see adelaidehillsnaturopath.com.au.


    • Hi KSK Mohan

      Thanks for your comments on this article. In regard to your request for information on corns, in all circumstances the best method of operation is to take a full case and, via the traditional process, in this case with specific reference to the location of thr pathology, arrive at the similimum and use this at the appropriate potency and dose. In my experience the remedies that are most often arrived at for corns are Ant crud, Sulphur, Lycopodium, Nit ac, Thuja, Calc carb, Nat mur, Arnica, Ferrum pic, Ignatia and Nat carb. I hope this is of use.

      Robert Medhurst

        • Hi Maryam
          That depends on the owner of the corns. You need to consider why the corns are there. In my experience they’re normally the product of a much longer process than simply the isolated development of corns. So it’s not just the corns you need to look at. As with all things in homeopathy you need to look at the owner in their entirety; not just at their corns. If it’s a deep-seated pathology and a good match with the rest of the proving symptoms for the remedy I normally use a 200C. If it’s less so but still a good match I use a 30C, if there’s little to go on mentally but the physicals and modalities are a good match I start with a 6C. I hope this helps

    • Hi Zia Ul Haq Siddiqui

      Thank you for your interest in this article. You should use whatever the symptoms dictate- if you or someone else is sufering from symptoms that are synonymous with the proving symptoms of Bryonia, then you’re obliged to use it. The reason that I haven’t included Bryonia in this table is that, for me, it rarely comes up when I’m analysing rheumatism cases, mostly because bryonia is characterised by an aggravation from motion and the majority of people I see, when it comes to their symptoms that relate to motion, have symptoms that are not consistent with this remedy. I know it’s mentioned in the materia medicas for rheumatism, but I don’t see it. I hope that helps.

      • Thanks you very much Dr Robert it,s realy very useful for me becaus my wife 55 RH factor + since 8 years suffring with joint pain mostly in knee and foot and shoulder pain increasing with movment rubing sound coming from knee when move sweling on knees pain in knees mostly in morning time.pleas advice.Thanks

        • Bryonia may well be useful in this case but I’m afraid that I can’t prescribe anything specifically for her via this medium. To do justice to your wife’s needs someone would need to discuss this with her face to face and take a proper case and unfortunately I’m not in a position to do this. I hope she’s able to to get some relief from this condition.

  • Dr. Medhurst,
    I believe Phytolacca is an excellent remedy for sciatica, especially if the outer sciatic nerve is involved. Dr. Nash speaks highly of its efficacy. I guess sciatica does not fall in the ambit of rheumatism?

    • Hi Nisar
      Thanks for your comment. Phytolacca is useful here although I see it more for right-sided sciatica and while it often comes up for this condition, I see Ars, Gnaph, Rhus tox, Nux v, Ruta, Cham, Colocynthis and Lyc more frequently. Sciatica is not normally included in the group of clinical conditions associated with rhwumatism.

  • I am one of the luck practionar who has treated two paitent of Rheumatism. They had lost the hope because Doctors (Allopathic) has left them alon. they were on bed. One of them was male of 45 and other was Female of 25 years old. both had got swallon and cannot banned thier knees, fingers of hands. Girl body was fully swallon.
    Now i have only one complaint left in girl patien. She is having feeling of “Broken Glass” and pain in the knee.
    Thanks for Homeopathic and for this aritical.
    I wrote this experience just for the new light Arithics.

    • thankyou Dr.Rana for your experince, but please mention the medicine name given to your both rheumatic case. thank you

  • Mr. M.A.Rana thank u very much for your experience in hte Rheumatic case,but can you please mention the name and the potency of medicine used for your two patients? thank you.

  • Thank you very much for your this informative article.
    I would like to add some more information to make the article much more informative.Find here some more information.

    Homeopathic Options
    Chronic arthritis with a feeling of bruising and soreness may be helped by this remedy. The painful parts feel worse from being moved or touched. (Herbal Arnica gels and ointments may also help to soothe arthritic pain when applied externally to areas of inflammation and soreness.)
    Aurum metallicum
    Wandering pains in the muscles and joints that are better from motion and warmth, and worse at night, suggest a need for this remedy. Deep pain may be felt in the limbs when the person tries to sleep, or discomfort may wake the person up. People who need this remedy are often serious and focused on work or career, with a tendency to feel depressed.
    This remedy can be helpful for stiffness and inflammation with tearing or throbbing pain, made worse by even the smallest motion. The condition may have developed gradually, and is worse in cold dry weather. Discomfort is aggravated by being touched or bumped, or from any movement. Pressure brings relief (if it stabilizes the area) and improvement also comes from rest. The person may want to stay completely still and not be interfered with.
    Calcarea carbonica
    This remedy may be useful for deeply aching arthritis involving node formation around the joints. Inflammation and soreness are worse from cold and dampness, and problems may be focused on the knees and hands. Weakness in the muscles, easy fatigue from exertion, and a feeling of chilliness or sluggishness are common. A person who needs Calcarea is often solid and responsible, but tends to become extremely anxious and overwhelmed when ill or overworked.
    This remedy may be indicated when deformities develop in the joints, in a person with a tendency toward tendon problems, muscle weakness, and contractures. The hands and fingers may be most affected, although other joints can also be involved. Stiffness and pain are worse from being cold, and relief may come with warmth. A person who needs this remedy often feels best in rainy weather and worse when the days are clear and dry.
    Calcarea fluorica
    This remedy is often indicated when arthritic pains improve with heat and motion. Joints become enlarged and hard, and nodes or deformities develop. Arthritis after chronic injury to joints also responds to Calcarea fluorica.
    If arthritis flares up during cold damp weather, or after the person gets chilled and wet, this remedy may be indicated. People needing Dulcamara are often stout, with a tendency toward back pain, chronic stiffness in the muscles, and allergies.
    Kali bichromicum
    When this remedy is indicated, arthritic pains may alternate with asthma or stomach symptoms. Pains may suddenly come and go, or shift around. Discomfort and inflammation are aggravated by heat, and worse when the weather is warm.
    Kali carbonicum
    Arthritis with great stiffness and stitching pains, worse in the early morning hours and worse from cold and dampness, may respond to this remedy-especially if joints are becoming thickened or deformed. People who need this remedy often have a rigid moral code, and tend to feel anxiety in the stomach.
    Kalmia latiflora
    Intense arthritic pain that flares up suddenly may responds to this remedy-especially when problems start in higher joints and extend to lower ones. Pain and inflammation may begin in the elbows, spreading downward to the wrists and hands. Discomfort is worse from motion and often worse at night.
    Ledum palustre
    Arthritis that starts in lower joints and extends to higher ones may respond to this remedy. Pain and inflammation often begin in the toes and spread upward to the ankles and knees. The joints may also make cracking sounds. Ledum is strongly indicated when swelling is significant and relieved by cold applications.
    If rheumatoid arthritis pain is changeable in quality, or the flare-ups move from place to place, this remedy may be useful. The symptoms (and the person) feel worse from warmth, and better from fresh air and cold applications. People who need this remedy usually are emotional and affectionate, sometimes having teary moods.
    This remedy is strongly indicated if swelling and soreness flare up before a storm, continuing until the weather clears. Cold and dampness aggravate the symptoms. Discomfort is often worse toward early morning, or after staying still too long. The person feels better from warmth and gentle motion, and also after eating.
    Rhus toxicodendron
    Rheumatoid arthritis, with pain and stiffness that is worse in the morning and worse on first motion, but better from continued movement, may be helped with this remedy. Hot baths or showers, and warm applications improve the stiffness and relieve the pain. The condition is worse in cold, wet weather. The person may feel extremely restless, unable to find a comfortable position, and need to keep moving constantly. Continued motion also helps to relieve anxiety.
    Ruta graveolens
    Arthritis with a feeling of great stiffness and lameness, worse from cold and damp and worse from exertion, may be helped with this remedy. Tendons and capsules of the joints can be deeply affected or damaged. The arthritis may have developed after overuse, from repeated wear and tear.
    Homeopathy Dosage Directions
    Select the remedy that most closely matches the symptoms. In conditions where self-treatment is appropriate, unless otherwise directed by a physician, a lower potency (6X, 6C, 12X, 12C, 30X, or 30C)

  • if Osteoporesis also comes under Rehumtism what are the remedies that can stop
    Bone loss and help building in new Bones

    • Hi Vijai Kapoor
      Thanks for your interest in this article. As with all things in homeopathy it’s always best to think of treating the whole person rather than just the disease they’re experiencing. In Osteoporosis, the remedies I’ve found to arise most frequently on repertorising the symptoms of people in this state are Calc carb, Silica, Symphytum and Vermiculite. I hope this is of use.
      Robert Medhurst

  • Deares sir,I want to upload my thesis on Rheumatoid Arthritis and its Management under various Therapies for ur and reader information.Any one can cantact me on [email protected].


    A Thesis Submitted to Open International University for Complementary Medicines (Pakistan Campus) affiliated to Open International University for Complementary Medicines
    (OIUCM) Colombo in Fulfillment of the Requirements for the Degree of

    Doctor of Alternative Medicines, MD (Alt.Med)


    DHMS, RHMP, M.Sc (Biochemistry)


    Name: Dr.Wali Khan

    Degree: Doctor of Alternative Medicine, MD (Alt.Med)

    Title of Thesis: Rheumatoid Arthritis and its Management

    Examining Committee:

    Chairman: Prof.Dr.Mendis MBBS, MRCP, FRCP

    Signature and Seal: _____________________________________________

    Supervisor: Prof.Dr.Indrapala MBBS, PhD, D.Sc

    Signature and Seal: _______________________________________________

    Date of Approval:______________________________________________

    I dedicate this humble effort, the fruit of my thoughts and study to
    my affectionate father and mother who groomed and inspired me to
    higher ideas of life.


    It is the day of great pleasure for me that with the blessing of Almighty Allah and my continuous hard work I have achieved my target to complete this thesis.
    I am very thankful to Homoeopathic Professor Dr Inamullah Mirza Ex-President National Council for Homoeopathy (Govt: Pakistan) for providing me this opportunity to complete this thesis. He always responded quickly whenever, I called him for guidance.
    I am also thankful to Assistant Professor Dr.Roshan Ali PhD (Biotechnology) Department of Biochemistry Khyber Medical University Peshawar Khyber Pakhtunkhwa for his generous guidance.
    I am also thankful to my mother and grand mother who always prayed for my success in all fields of life and after death.
    I am very thankful to Mr.Fazal Rahim junior clerk NTFP Department Bajaur Agency who worked day and night on computer for typing this thesis.

    Homoeopathic Doctor Wali Khan
    DHMS, RHMP, M.Sc (Biochemistry)


    There are over 400,000 people with rheumatoid arthritis (RA) in the UK.Although this makes it a common disorder, there are numerous other conditions ahead of it in terms of numbers, and indeed as causes of excess mortility.What this does not capture however, is the dreadful morbidity associated with the disease. The synovitis.Four of RA affects multiple sites causing widespread pain, and the subsequent destruction of the joints can lead to severe disability affecting all aspects of motor function from walking to fine movements of hand.Further-more,RA is not simply a disease of the joints but can affect many other organs causing, for example, widespread vasculitis or severe lung fibrosis. More recently it has become apparent that RA is associated with an increased prevalence of coronary artery disease and significant increased risk of premature mortality.
    Fortunately there are a considerable number of disease-modifying and anti-inflammatory agents which can significantly reduce the impact of RA.Some of these, for example corticosteroids,sulphasalazine or methotrexate,have been available for many years, and rheumatologists are well used to balancing the benefits and side-effects of these drugs. More recently, targeted disease-modifying and anti-inflammatory therapies, particularly the anti-TNF agents, have emerged, and have proved effective in many patients. While it is encouraging that there is such a wide range of treatment available, the choice brings with it difficult questions concerning the best sequencing of therapy. Moreover, the newer drugs are expensive. The high impact of the disease and the need to make best use of the available treatment RA a highly suitable subject for the rheumatologists and other professionals.
    This venture is a modest attempt to present to the reader a Synopses of a veritable disease which is generally not taken as a serious cause for concern.
    Most often it is reckoned as an ailment of trivial significance, despite, its wide and wild effects upon general health and well being of the peoples. Statistics with respect to the magnitude, extent and prevalence of the disease in Pakistan are too inadequate. And practically speaking there is no reliable data base is available on the topic Rheumatoid Arthritis.
    The salient features highlighted in this article show the way for forward planning and study in greater depth.
    A comparative study of the various therapies, briefly discussing their merits and demerits has also been sufficiently incorporated the value and worth of any type of medical treatment must necessary rest upon:
     Simplicity
     Efficacy and adequacy
     Economy in cost
     Harmlessness
     Availability of expertise
     Popularity
     Duration of treatment till cure
     Commitment and dedication of the professionals
     No opinion has been expressed about the preference of one thereby over the other, this being a matter for the experts from every discipline to decide in particular and individual cases.
    The opening chapters of this article present over all view and explain what Rheumatoid Arthritis is? The scope of this dissert under the guide lines provided by the Open International University for Complementary Medicines Colombo (OIUCM), has been kept in view and dealt with accordingly.
    Appropriate and effective management of Rheumatoid Arthritis is based upon:
     Etiology
     Epidemiology
     Immunopathogenesis
     Diagnosis
     Prognosis
     Treatment under various therapies
     Prevention and Cure

    The desertion has been prepared in fulfillment of pre-requisite and as a part of curriculum exercise toward the accomplishment of the MD degree programme the OIUCM.

    Homoeopathic Doctor Wali Khan
    DHMS, RHMP, M.Sc (Biochemistry)

    Table of Contents: Page#

    Dedication i
    Acknowledgment ii
    Preface iii
    List of Abbreviations ix
    CHAPTER -1 1
    1.1 Complementary and alternative medicines: 1
    1.2 Alternative Medicine 3
    CHAPTER – 2 7
    2.1 Introduction to rheumatoid arthritis 7
    CHAPTER – 3 9
    3.1Signs and Symptoms of Rheumatoid arthritis 9
    3.2 Joints 10
    3.3 Deformities 11
    3.3.1 Hands and wrists 11
    3.3.2 Feet and ankles 11
    3.3.3 Knee 12
    3.3.4 Cervical Spine 12
    3.4 Skin 13
    3.5 Lungs 14
    3.6 Kidneys 14
    3.7 Heart and blood vessels. 15
    3.8 Other 15
    3.8.1 Musculoskeletal 15
    3.8.2 Ocular 15
    3.8.3 Hepatic 16
    3.8.4 Hematological. 16
    3.8.5 Neurological 16
    3.8.6 Constitutional symptoms 17
    3.8.7Osteoporosis 17
    3.8.8 Lymphoma 17
    CHAPTER – 4 18
    4.1 Diagnosis 18
    4.1.1 Physical Examination 18
    4.1.2 Imaging 23
    4.1.3 Blood tests 24
    CHAPTER – 5 27
    5.1 Rheumatoid arthritis classification criteria 27
    5.2 Types of Rheumatoid Arthritis 29
    5.3 Juvenile Rheumatoid Arthritis 31
    5.4 Palindromic Rheumatoid Arthritis 32
    5.5 Pannus Rheumatoid Arthritis 33
    5.6 Seronegative Rheumatoid Arthritis 35
    5.7 Seropositive Rheumatoid Arthritis 36
    CHAPTER- 6 37
    6.1 Differential diagnoses 37
    6.2 Diseases with Symptoms Similar to Rheumatoid Arthritis 40
    6.3 Monitoring progression 40
    CHAPTER- 7 42
    7.1 Pathophysiology and causes 42
    7.2 Possible infectious triggers 43
    7.3 Psychological factors 44
    7.4 Continued abnormal immune response 44
    7.5 Role of vitamin D 45
    CHAPTER – 8 48
    8.1 Complications 48
    CHAPTER- 9 49
    9.1 Rheumatoid arthritis and pregnancy 49
    9.2 Rheumatoid arthritis makes it difficult to conceive 49
    CHAPTER-10 51
    10.1 Management of Rheumatoid Arthritis under various therapies 52
    10.2 Disease modifying anti-rheumatic drugs (DMARDs) 53
    10.3 Traditional small molecular mass drugs 53
    10.4 Agents biological 56
    10.5 DMARDs for Treatment of Rheumatoid Arthritis 57
    10.6 Anti-inflammatory agents and analgesics 62
    10.7 Surgery. 64
    10.8 Non-Pharmacological Treatment. 64
    10.9 Other therapies 65
    10.9.1 Homeopathic Treatment of Rheumatoid Arthritis

    10.9.2 Acupuncture for Rheumatoid Arthritis 72
    10.9.3 Ayurveda for Rheumatoid Arthritis.
    10.9.4 Reflexology. 76
    10.9.5 Yoga Treatment of Rheumatoid Arthritis. 79
    CHAPTER- 11 79
    11.1 Prognosis: 81
    11.2 Prognostic factors 81
    11.3 Mortality 81
    CHAPTER-12 82
    12. Epidemiology 82
    CHAPTER -13 83
    13. History 83
    CHAPTER- 14 84
    14. Photographs 84
    15. References 115

    List of Abbreviations

    ANA Antinuclear Antibody
    ACR American College of Rheumatology
    ALT Alanine Transaminase
    AST Aspartate Transaminase
    ACPAs Anticitrullinated Protein Antibodies
    CAM Complementary Alternative Medicine
    CBC Complete Blood Count
    CCP Cyclic Citrullinated Peptide
    CRP C-Reactive Protein
    CNHC Complementary and Natural Healthcare Council
    DNA Deoxy Ribonucleic Acid
    DAS Disease Activity Score
    DIP Distal Interphalangeal
    DMARs Disease Modifying Anti Rheumatic Drugs
    ESR Erythrocyte Sedimentation Rate
    EULAR European League Against Rheumatism
    EBV Epstein-Barv Virus
    FDA Food and Dietary Allowance
    IV Intravenous
    IL Inter Leukin
    LFTs Liver Function Tests
    MMPs Matrix Metalloproteases
    MCH Major Histocompatibility Complex
    MTP Metatarsophalangeal
    MCP Metacarpophalangeal
    MCV Muted Citrullinated Vimentin
    MRI Magnetic Resonance Image
    MTX Methotrexate
    NIH National Institute of Health
    NHIS National Health Interview Surveys
    NSAIDs Non Steroidal Anti Inflammatory Drugs
    PIP proximal interphalangeal
    POCT Point of Care Test
    RA Rheumatoid Arthritis
    RF Rheumatoid Factor
    ROM Range of Motion
    SA Subjective Assessment
    SC Subcutaneous
    SSZ Sulfasalazine
    SLE Systemic lupus erythematosus
    TB Tuberculosis
    TCM Traditional Chinese Medicines
    TNF Tumor necrosis factor
    T IAs Transient Ischemic Attack
    VDR Vitamin D Receptor
    WBC White Blood Cell
    WHM Western Herbal Medicines
    WHO World Health Organization

    CHAPTER – 1


    General Considerations:


    CAM is defined by the Nation Institutes of Health (NIH) as a group of diverse health care systems, practices, and products that are not presently considered to be part of conventional medicine.

    CAM therapies may be used along an alternative to conventional therapies or in addition to conventional, mainstream medicine to treat condition and promote will being.


    CAM modalities have been classified by NIH into five major categories.
    Include botanicals, dietary supplements, probiotics, vitamins, minerals, certain
    diets and nutritional practices, and more.

     Energy medicine involves the use of energy fields, such as magnetic fields or biocides (energy fields that some believe surround and penetrate the human body).Examples include Raieki, external qigong and therapeutic touch.

     Manipulative and body-based practices. Use manipulation or movement of one or more body parts (e.g., massage, chiropractic, Feldenkrais method and other “body work” systems).

     Mind-body medicine uses a variety of techniques design to enhance the integration between mind and body, such as biofeedback, meditation, art and music therapy, hypnosis and guided imagery.

    Whole medical systems are built on complete systems of theory and practice that have evolved apart from and often earlier than the conventional medical approach used in the United States. Systems such as traditional oriental medicine, acupuncture, homeopathy, naturopathy, Ayurvede, and Tibetan medicine often use one or more of the methods listed above.

    The Centers for Disease Control and Prevention conducted National Health interview Surveys (NHIS) in 2002 and 2007.Overall, 23,000 American adults from diverse populations were asked about their use of CAM in the 2007survey. Thirty-eight present reported using some form of CAM in the previous 12 months, essentially unchanged form 36% in 2002. The most commonly used CAM therapies were non- vitamin,nonmineral nature products (17.7%), with fish oil, gluscosamine, Echinacea, flaxseed and ginseng being most common; deep breathing exercises (12.7%); meditation (9.4%). Chiropractic or osteopathic manipulation (8.6%); massage (8.3%); and yoga (6.1%).CAM use was higher levels of educations, who were not poor, who live in the West and who have quit cigarette smoking.

    The most common conditions for which and adults used CAM were similar to those seen in most primary care offices; musculoskeletal complaints, such as back, neck, and joint pain.

    Funding for biomedical research in this filed increased when the NIH
    established the Office of alternative Medicine in 1992 with an annual budget of $2 million. In 1998, its role was expanded as the National Center for Complementary and Alternative Medicine (NCCAM).NCCAM’s budget for fiscal year 2009 was $2 million. Although some CAM modalities are not easily evaluated using randomized control trial methodology, the 2005 Institute of Medicine report recommends that conventional and CAM treatments both be held to similar standards of safety and efficacy.

    1.2 Alternative Medicine

    Orthodox and holistic approaches to medicine

    Alternative medicine is based on holistic principles.

    Conventional medicine is based on very detailed and specific scientific knowledge.

    Health is seen as simply an absence of symptoms, ill-health as a malfunction in the body or mind system that has to be corrected.

    The emphasis is on fighting, conquering and destroying disease with use of drugs, surgery or sometimes hard treatment of the mind.

    The mind and body are seen as separate entities and are treated by different disciplines, the spirit is ignored.

    The focus is on symptoms of disease and it is the symptoms that will be treated while other needs of the person will largely ignored.

    An imbalance in the relationship between doctor and patient may be created’

    Aims to deal with the patient as a whole, not merely with physical symptoms.

    Holistic Practioners:

    They assume a person exists on many levels and take into account not only the body but also the mind and spirit (the animating vital principle) of an individual. The mind and spirit are not seen simply as part of the body; each is considered to be a complete system, constantly interacting with one another and of equal importance. The three systems, that is mind body and spirit, can be said to be integrated principles of the whole. Holistic practitioners believe the mind, body and spirit of an individual tend naturally towards a state of balance, known in the West as homeostasis.

    For example, prolonged stress may unbalance the mind that causes the body to react with various symptoms, such as pain or fatigue. The spirit, too, may become unbalanced and depression may occur.
    Holistic practitioners tend to focus on the underlying cause rather than
    on symptoms of an aliment.

    When there is a problem

    Any treatment provided aims

    Holistic practitioners would almost certainly suggest that to control symptoms would not be able to deal with the underlying disturbances that are creating these symptoms. Not only do drugs prevent elimination of impurities but that they might add toe toxins already prevalent.
    Surgery is thought to destroy homeostasis and is seen as necessary only in the last resort. While it is accepted that a vieus may trigger an illness, it is thought there is probably a state of susceptibility to disease already prevalent n the individual owing to an imbalance in the mind, which cannot be treated with surgery.

    Alternative Therapies in the west:

    Alternative therapies come from all over the world. Some, such as Ayurveda, from India, acupressure, acupuncture and Chinese herbal medicine from China, known collectively as Traditional Chinese Medicine (TCM), and Western Herbal Medicine (from Europe).

    Homoeopathy from Germany osteopathy from USA, aromatherapy (from France), Bach flower remedies (from England).Biofeedback (from the USA).
    Until about the mid-1970s alternative therapies were collective known as “fringe” and labeled unconventional or unorthodox practices.

    Alternative, however, embraces all practices that are not orthodox and it is the word used to describe therapies that are not part of conventional medical practice in USA.


    About half the total population of Australia is reckoned to use at least one non-medically prescribed remedy each year and one-quarter of the total population consult and alternative therapy.
    It is not permitted to treat certain diseases, such as cancer, by any alternative therapy. The three most popular therapies are probably massage, naturopathy, Chinese and Western herbal, medicine.

    New Zeeland:

    Chiropractors and osteopaths in New Zeeland are registered as medical auxiliaries.

    South Africa:

    An act in 1982 in South Africa incorporated all alternative practitioners into a register supervised by the Associated Health Service Professional Board. It has the same status as the orthodox practitioners’ register.

    United Kingdom:

    In the UK chiropractic and osteopathy are registered therapies and members of the registering boards are allowed to practice. Practitioners of almost any therapy have the right to practice under common law as except they cannot be involved with dentistry, midwifery, veterinary surgery or treat venereal, disease. No treatment or remedies for cancer can be advertised but anyone is allowed to treat the disease.
    In 1995 a consumers Association survey showed healing, osteopathy, chiropractic, homeopathy, aromatherapy and acupuncture to be the most popular alternative therapies, while aromatherapy is the fastest growing.

    In the USA each of the 50 states decides its own policy regarding alternative medicine. In most states alternative techniques are described. Chiropractic, the most popular alternative therapy, is registered by all states and doctors refer to and receive referrals chiropractors.

    While herbal medicine is banned in many states. New York State however recognizes all therapies and supports freedom of choice in health. Ayurveda, chiropractic and TCM are very popular therapies, aromatherapy and homoeopathy less so.
    Health is perceived to be not merely the absence of disease but a positive quality of living.

    Patients demand to be more actively involved knowledgeable about, their own health.
    There is a fear of conventional drug treatment and surgery.
    Patients are becoming aware of the limitations of orthodox medicine.
    Patients want more communication with, and more information from, their doctors than they receive.

    CHAPTER – 2
    Rheumatoid arthritis is a chronic symmetrical polyarthritis of unknown cause and is characterized by chronic inflammatory synovitis of mainly peripheral joints along with systemic disturbances and extra-articular features. Course of disease is prolonged with exacerbations and remission. Characterized by:
     Symmetrical inflammatory polyarthritis
     Extra-articular involment e.g. in lungs and many other organs
     Progressive joint damage causing severe disability
    General consideration:
    Rheumatoid Arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks flexible (sensorial) joints. The process produces an inflammatory response of the capsule around the joints (synovium) secondary to swelling (hyperplasia) of synovial cells, excess synovial fluid, and the development of fibrous tissue (pannus) in the synovium.The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, membrane around the heart (pericardium), the membranes of the lung (pleura), and white of the eye (sclera), and also nodular lesions, most common in subcutaneous tissue.
    Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in both its chronicity and progression, and RA is considered a systemic autoimmune disease. About 1% of the world’s population is afflicted by rheumatoid arthritis, women three times more often than men. Onset is most frequent between the ages of 40 and 50, but people of any age can be affected.

    It can be a disabling and painful condition, which can lead to substantial loss of functioning and mobility if not adequately treated. It is a clinical diagnosis made on the basis of symptoms, physical exam, radiographs (X-rays) and labs, although the American College of Rheumatology (ACR) and the European league Against Rheumatism (EULAR) publish classification criteria for the purpose of research. Diagnosis and long-term management are typically performed by a rheumatologist, an expert in joint, muscle and bone diseases.
    Various treatments are available. Non-pharmacological includes physical, orthoses, occupational therapy and nutritional but these do not stop the progression of joint destruction. Analgesia (painkillers) and anti-inflammatory drugs, including steroids are used to suppress the symptoms, while disease-modifying antirheumatic drugs (DMARDs) are required to inhibit or halt the underlying immune process and prevent long-term damage. In recent times, the newer group of biologics has increased treatment options.
    The name is based on the term “rheumatic fever”, an illness which includes joint pain is derived from the Greek word pebua-rheuma (nom.),pebuaro – rheumatos (gen.) ( “flow, current”).The suffix-oid ( “resembling”) gives the translation as joint inflammation that resembles rheumatic fever. The first recognized description of rheumatoid arthritis was made in 1800 by Dr.Augustin Jacob Landre-Beauvais (1772-1840) of Paris.
    Signs and symptoms:
    While rheumatoid arthritis primarily affects joints, problems involving other of the body are known to occur. Extra-articular (“outside the joints”) manifestations other than anemia (which is very common) are clinically evident in about 15-25% of individuals with rheumatoid arthritis. It can be difficult to determine whether diseases manifestation are directly caused by the rheumatoid process itself, or from side effects of the medications commonly used to treat it – for example, lung fibrosis from methotrexate or osteoporosis from corticosteroids.

    CHAPTER – 3
    3.1 Signs and Symptoms of Rheumatoid arthritis

    The types and severity of symptoms of rheumatoid arthritis varies between individuals. At the onset of the disease, the symptoms of rheumatoid arthritis can be vague and develop slowly. They may not include the classic symptom of joint pain that people often associate with arthritis. These indistinct, early symptoms may include fatigue, loss of appetite, and weakness. Other early symptoms include muscle achiness throughout the body and stiffness that lasts more than one hour after rising in the morning. Ultimately, joint pain develops and can be accompanied by inflammation and swelling in the joints. Joint pain generally affects wrists, fingers, knees, feet, and ankles on both sides of the body. Joint destruction may develop within 1-2 years after the onset of the disease.

    Other symptoms may include problems with the eyes, deformities in the hands and feet, fever, paleness, anemia, nodules under the skin, swollen glands, and redness and inflammation of the skin.

    Because of the generalized inflammatory nature of rheumatoid arthritis, it can affect almost any organ in the body and lead to life threatening complications. These include rheumatoid vasculitis, a type of inflammation of the blood vessels, which can lead to atherosclerosis, stroke, heart attack and other cardiac conditions. Skin ulcerations and infections, bleeding stomach ulcers, and nerve problems that cause pain, numbness, or tingling may also occur. The eyes can also be affected and the neck bones can become instable.

    The list of signs and symptoms mentioned in various sources for Rheumatoid arthritis includes the 29 symptoms listed below:
     Joint pain
     Joint swelling
     Joint stiffness
     Morning joint stiffness
     Joint stiffness after inactivity
     Joint tenderness
     Warm joints
     Ankle arthritis
     Foot arthritis
     Finger arthritis
     Wrist arthritis

     Symmetrical joint pattern – both sides of the body afflicted
     Morning stiffness
     Weight loss
     Fatigue
     Decreased appetite
     Occasional fever
     Bouts of mild fever
     Malaise
     Episodic flares with remissions
     Variable symptoms – different people experience different effects
     Skin bumps (rheumatoid nodules) – about 25% of cases get these
     Anemia
     Neck pain
     Dry eyes
     Dry mouth
     Tiredness
     Afternoon fatigue
     Afternoon malaise

    3.2 Joints:
    The arthritis of joints known as synovitis is inflammation of the synovial membrane that lines joints and tendon sheaths. Joints become swollen, tender and warm, and stiffness limits their movement. With time RA nearly affects multiple joints (it is a polyarthritis), most commonly small Joints of the hands, feet and cervical spine, but larger joints like the shoulder and knee can also be involved. Synovitis can lead to tethering of tissue with loss of movement and erosion of the joint surface causing deformity and loss of function.
    Rheumatoid arthritis typically manifests with signs of inflammation, with the affected joints being swollen, warm, painful and stiff, particularly early in the morning on waking or following prolonged inactivity. Increased stiffness early in the morning is often a prominent feature of the disease and typically lasts for more than an hour. Gentle movement may relieve symptoms in early stages of the disease.

    These signs help distinguish rheumatoid from non-inflammatory problems of the joints, often referred to as osteoarthritis “wear-and tear” arthritis. In arthritis of non-inflammatory causes, signs of inflammation and early morning stuffiness are less prominent with stiffness typically less than 1 hour, and movements induce pain caused by mechanical arthritis. In RA, the joints are often affected in a fairly symmetrical fashion, although this is not specific, and the initial presentation may be asymmetrical.
    As the pathology progresses the inflammatory activity leads to tendon tethering and erosion and destruction of the joint surface, which impairs range of movement and leads to deformity. The fingers may surfer from almost any deformity depending on which joints are most involved.
    Although any joint may be affected in RA,the proximal interphalangeal and metacarpophalangeal joints of fingers as well as the wrist, knee ankles and toes are most often involved. Distal interphalangeal joints are characteristically spared.
    3.3 Deformities:
    As the disease advances (after months or year) pain, muscle spasm and joints destruction results in limitation of joint movement, joint instability, subluxation (partially dislocation) and deformities.
    3.3.1 Hands and wrists
     Spindling of fingers: In early stages, swelling of metacarpophalangeal joints produces spindling of fingers
     Anterior subluxation of the metacarpophalangeal joints along with ulnar deviation of fingers develops due to weakening of joint capsule and muscle wasting.
     Swan neck deformity: Characterized by hypertension at the proximal interphalangeal joints and fixed flexion at the distal interphalangeal joints
     Button hole deformity: Characterized by fixed flexion of the proximal interphalangeal joint and extension of the distal interphalangeal joint

     Z deformity of thumb: Characterized by hypertension of the first interphalangeal joint and flexion of the first metacarpophalangeal joint with consequent loss of thumb mobility
     Carpal tunnel syndrome: Tenosynovitis at the wrist can entrap the median nerve and produce carpal tunnel syndrome
    Extra-articular features in hands may be palmer erythema and vasculitic lesions in nail beds, nail folds, and digital pulp.
    3.3.2 Feet and ankles:
    Lateral deviation of the toes and subluxation (partially dislocation) of the metacarpophalangeal joints, so that the heads of the metatarsals become palpable in the soles of the feet and patient often describes as sensation of walking on pebbles. Ankle develops valgus deformity.
    3.3.3 Knee:
     Synovial effusions and quadriceps wasting are early features:
     Later on flexion, valgus (bent outwards) or varus (bent inwards) deformity appear with joint instability.
     Synovial effusion (demonstrated with patellar tap by fixing the knee fingers and thumb of left hand, then sharply tapping the patella downwards produces a dip when effusion is present.
     Baker’s Cyst: It is an extension of inflamed synovium into the popliteal space, causing pain and swelling. High pressure generated by flexion of knee can cause rupture of cyst into calf, manifesting as calf swelling, tenderness and pitting edema.
    3.3.4 Cervical Spine
    Synovitis of upper cervical spines leads to bone destruction, damage of ligaments that causes atlantoaxial subluxation which may damage the spinal cord.

    3.4 Skin:
    The rheumatoid nodule, which is often subcutaneous, is the coetaneous feature most characteristic of rheumatoid arthritis. It is a type of inflammatory reaction known to pathologists as a “necrotizing glaucoma”. The initial pathologic process in nodule formation is unknown but may be essentially the same as the synovitis, since similar structural features occur in both. The nodule has a central area of fibrinoid necrosis that may be fissured and which corresponds to the fibrin-rich necrotic material found in and around an affected synovial space. Surrounding the necrosis is a layer of palisading macrophages and fibroblasts, corresponding to the intimal layer in synovium and a cuff of connectives tissue containing clusters of lymphocytes and plasma cells, corresponding to the suboptimal zone in synovitis.
    The typical rheumatoid nodule may be a few millimeters to a few centimeters in diameter and is usually found over bony prominences, such as the colcannon, the calcaneal tuberosity.the metacarpophalangeal joints, or other areas that sustain repeated mechanical stress.
    Nodule is associated with a positive RF (rheumatoid factor) titer and severe erosive arthritis. Rarely, these can occur in internal organs or at diverse sites on the body.
    Several forms of vasculitis occur in rheumatoid arthritis. A benign form occurs as micro infarcts around the manifolds. More severe forms include livedo reticular is, which is a network (reticulum) of erythematous to purplish discoloration of the skin caused by the presence of an obliterative coetaneous capillaropathy. Other, rather rare, skin associated symptoms include:
     Pyoderma gangrenosum, a necrotizing,ulcerative,noninfectious neutrophilic dermatosis.
     Sweet’s syndrome, a neutrophilic dermatosis usually associated with myeloproliferative disorders.

     Drug reactions.
     Erythematic nodoseum
     Lobular panniculitis
     Atrophy of digital skin
     Palmar erythema
     Diffuse thinning (rice paper skin), and skin fragility (often worsened by corticosteroid use).
    3.5 Lungs:
    Fibrosis of the lungs is a recognized response to rheumatoid
    disease. It is also a rare but well recognized consequence of therapy (for example with methotrexate and leflunomide) Caplan,s syndrome describes lung nodules in individuals with rheumatoid arthritis and additional exposure to coal dust. Pleural effusions are also associated with rheumatoid arthritis. Another complication of RA is rheumatoid lung Disease. It is estimated that about one quarter of Americans with develops Rheumatoid Lung Disease.

    3.6 KIDNEYS
    Renal amyloidosis can occur as a consequence of chronic inflammation. Rheumatoid arthritis may affect the kidney glomerulus’s directly through a vasculopathy or a mesangial infiltrate but this is less well documented (though this is not surprising, considering immune complex-mediated hypersensitivities are known for pathogenic deposition of immune complexes in organs where blood is filtered at high pressure to form other fluids, such as urine and synovial fluid) Treatment with Penicillamine and gold salts are recognized causes of membranous nephropathy.

    People with rheumatoid arthritis are more prone to atherosclerosis, and risk myocardial infarction (heart attack) and stroke is markedly increased.
    Other possible complications that may arise include: pericarditis, endocarditic, left ventricular failure, valaulitis and fibrosis. Many people with rheumatoid arthritis do not experience the same chest pain that others feel when they have angina or myocardial infarction. To reduce cardiovascular risk, it is crucial to maintain optimal control of the inflammation caused by rheumatoid arthritis (which may be involved in causing the cardiovascular risk factors such as blood lipids and blood pressure. Doctors who treat rheumatoid arthritis patients should be sensitive to cardiovascular risk when prescribing anti-inflammatory medications, and may want to consider prescribing routine use of low doses of aspirin if the gastrointestinal effects are tolerable
    3.8 OTHER
    3.8.1 Musculoskeletal
    Subcutaneous nodules (In 20%): Usually seen at sites of pressure or friction such as the exterior surfaces of the forearms below the elbow, scalp, sacrum, scapula.A chilles tendon, as well as on the fingers and toes.
     Bursitis: The olecranon and other bursae may become swollen.
     Tenosynovitis: Particularly affecting the flexor tendons in the palm of the hand and may contribute to flexion deformities.
     Muscle wasting: around affected joints especially in the hands.
    3.8.2 Ocular:
    The eye is directly affected in the form of episcleritis which when severe can very rarely progress to perforating scleromalacia.Rather more common is the indirect effect of keratoconjunctivitis sicca, which is a dryness of eyes and mouth caused by lymphocyte infiltration of lacrimal and salivary glands. When severe, dryness of the cornea can lead to keratitis and loss of vision. Preventive treatment of severe dryness with measures such as nasolacrimal duct occlusion is important.

    3.8.3 Hepatic:
    Cytokine production in joints and /or hepatic Kupfer cells leads to increased activity of hepatocytes with increased production of acute-phase proteins, such as C-reactive protein, and increased release of enzymes such as alkaline phosphates into the blood. In Fealty’s syndrome, Kuppfer cell activation is so marked that the resulting increase in hepatocyte activity is associated with nodular hyperplasia of the liver, which may be palpably enlarged. Although Kupffer cells are within the hepatic parenchyma, they are separate from hepatocytes.As a result there is little or no microscopic evidence of hepatitis (immure-mediated destruction of hepatocytes).Hepatic involvement in RA is essentially asymptomatic.
    3.8.4 Hematological:
    Anemia is by far the most common abnormality of the blood cells.
    Rheumatoid arthritis may cause a warm autoimmune hemolytic anemia.
    The red cells are of normal size and color (normocytic and normochromic).A low white blood cell count (Neutrogena) usually only occurs in patients with Fehy’s syndrome with an enlarged liver and spleen. The mechanism of neutropenia is complex. An increased platelet count (thrombocytosis) occurs when inflammation is uncontrolled; as does the anemia. Iron deficiency may also be present due to GIT blood loss from analgesic ingestion.

    3.8.5 Neurological :
    Peripheral neuropathy mononeuritis multiplex may occur. The most common problem is carpal tunnel syndrome caused by compression of the median nerve by swelling around the wrist.Atlanto-axial subluxation can occur, owing to erosion of the odontoid process and or transverse ligaments in the cervical spine’s connection to the skull. Such an erosion (>3mm) can give rise to vertebrae slipping over one another and compressing the spinal cord. Clumsiness is initially experienced, but without due care this can progress to quadriplegia.

    3.8.6 Constitutional symptoms:
    Constitutional symptoms including fatigue, low grade fever, malaise, and morning stiffiness, loss of appetite and loss of weight are common systemic manifestations seen in patients with active rheumatoid arthritis.
    3.8.7 Osteoporosis:
    Local osteoporosis occurs in RA around inflamed joints. It is postulated to be partially caused by inflammatory cytokines. More general osteoporosis is probably contribution to by immobility, systemic cytokine effects, and local cytokine release in bone marrow and corticosteroid therapy.
    3.8.8 Lymphoma:
    The incidence of lymphoma is increased in RA, although it is still uncommon.

    CHATER – 4
    4.1 Diagnosis:
    Diagnosis of RA is based on history, examination, X-Ray findings and serology (RA factor).Rheumatoid arthritis presents initially with non specific symptoms but assume its characteristic features with in 1-2 years of onset. The following features support diagnosis of rheumatoid arthritis.
     Bilateral symmetrical inflammatory polyarthritis involving small and large joints both the upper and lower extremities with sparing of axial skeleton except cervical spine suggest diagnosis
     Systemic features indicative of inflammatory nature of disease such as morning stiffness support the diagnosis
     Presence of subcutaneous nodules is helpful diagnostic feature.
    4.1.1 Physical Examination:

    Joint involvement is the characteristic feature of rheumatoid arthritis. In general, the small joints of the hands and feet are affected in a relatively symmetric distribution. In decreasing frequency, the MCP, wrist, PIP, knee, MTP, shoulder, ankle, cervical spine, hip, elbow, and temporomandibular joints are most commonly affected. Affected joints show inflammation with swelling, tenderness, warmth, and decreased range of motion (ROM). Atrophy of the interosseous muscles of the hands is a typical early finding. Joint and tendon destruction may lead to deformities such as ulnar deviation, boutonniere and swan-neck deformities, hammer toes, and, occasionally, joint ankylosis.

    Other commonly observed musculoskeletal manifestations include tenosynovitis (defined as inflammation of the tendon and its enveloping tendon sheath ) and associated tendon rupture due to tendon and ligament involvement, most commonly involving the fourth and fifth digital extensor tendons at the wrist; periarticular osteoporosis due to localized inflammation; generalized osteoporosis due to systemic chronic inflammation, immobilization-related changes, or corticosteroid therapy; and carpal tunnel syndrome. Most patients with RA have muscle atrophy from disuse, which is often secondary to joint inflammation.

     Fingers:

    The boutonniere deformity, demonstrated in the image Fig N0.6 , describes nonreducible flexion at the PIP joint along with hyperextension of the distal interphalangeal (DIP) joint of the finger. This deformity occurs as a result of synovitis stretching or rupturing the PIP joint through the central extensor tendon, with concomitant volar displacement of the lateral bands. When the lateral bands have subluxed far enough to pass the transverse axis of the joint, they become flexors of the PIP joint.

    Hyperextension of the DIP joint occurs as the tendons shorten with time. A compensatory and reducible hyperextension may occur at the MCP joint. Consequences of boutonniere deformity are loss of thumb mobility and pincher grasp.

    Swan-neck deformity of the finger describes hyperextension at the PIP joint
    with flexion of the DIP joint (see the image Fig NO.7). The deformity may be
    initiated by (1) disruption of the extensor tendon at the DIP joint with secondary
    shortening of the central extensor tendon and hyperextension of the PIP joint,
    or (2) volar herniation of the PIP joint capsule due to weakening from
    chronic synovitis with subsequent tightening of the lateral bands and central
    extensor tendon. The lateral bands may become shortened over time and lie
    dorsally, limiting PIP flexion and ineffectively extending the DIP joint.

    Tightness of intrinsic muscles (eg, interossei, lumbricals) may cause major
    declines in mobility of the fingers. This characteristic is ascertained on
    examination when the PIP joint cannot be flexed while the MCP joint is fully
    extended, but it can be flexed if the MCP is in flexion (Bunnell test); primary PIP
    joint pathology would be evident with the MCP joint in either position. To assess
    this accurately, the phalanx must be aligned with the metacarpal, as the intrinsic
    muscles on the ulnar side are slack when ulnar deviation at the MCP joint exists,
    thus allowing more motion.

    Flexor tenosynovitis of the fingers is common and suggests a poor prognosis. “Triggering” of the finger occurs when thickening or nodule formation of the tendon interacts with the concomitant tenosynovial proliferation, trapping the tendon in a flexed position (stenosing tenosynovitis). Tendon rupture may occur due to infiltrative synovitis in the digit or bony erosion of the tendon at the wrist (especially the flexor pollicis longus).

    Arthritis mutilans (sometimes called opera glass hands) results if destruction is severe and extensive, with dissolution of bone. In the small joints of the hands, the phalanges may shorten and the joints may become grossly unstable. Pulling on the fingers during examination may lengthen the digit much like opening opera glasses, or the joint may bend in unusual directions merely under the pull of gravity. Aso see the image Fig NO.13 for hand deformities.

     Metacarpophalangeal joints:

    As seen in the image Fig NO.8 , 2 typical deformities that alter the alignment of the palmar skeletal arches and the stability of the fingers may occur at the MCP joints: volar subluxation and ulnar deviation. Most cases of ulnar deviation are accompanied by counterpoised radial deviation of the wrist, roughly proportional to the degree of ulnar deviation of the fingers. The volar plate is firmer and more substantial than other portions of the MCP joint capsule and, therefore, effectively limits extension and dorsal movement at the joint. The greater strength of the flexor muscles relative to the extensor muscles causes volar migration of the proximal phalanx after synovial-based inflammation has weakened ligament and tendon insertions about the MCP joint capsule.

    Ulnar deviation occurs after synovitis has led to stretching and attenuation of the volar plate and collateral ligaments, allowing dislocation of the flexor tendon volarward and ulnarward. The supporting structures of the extensor tendons also may become attenuated or destroyed by synovial distention and invasion, loosening the tendons so that they no longer ride centrally and dorsally over the metacarpal head but move into the cleft between the MCP joints. If the extensor tendon subluxation is beyond the transverse axis of the MCP joint, the tendon becomes a flexor at that joint, further limiting the active extension of the fingers.

     Wrists:

    Multiple deformities may occur in the wrist. Disruption of the radioulnar joint with dorsal subluxation of the ulna (caput ulna), as well as rotation of the carpus on the distal radius with an ulnarly translocated lunate, is common. The combination of an ulnar drift of the fingers and carpal rotation is known as a zigzag deformity. Shortening of the carpal height (noted on radiographs), due in part to cartilage loss, is seen with rotational deformities.

    Dorsal subluxation of the ulna often allows the ulnar styloid to be depressed volarly on examination, much like depressing a piano key. Subluxation may lead to rupture of the extensor tendons of the little, ring, and long fingers, because the end of the distal ulna is roughened secondary to erosion of bone and may abrade the tendons as they move back and forth during normal hand function, much like a rope being frayed while rubbing over a sharp rock. This process is especially likely to lead to tendon rupture if there is associated tenosynovitis. (See the image Fig No.9)
    Entrapment neuropathy may result from synovitis about the flexor tendons. Entrapment of the median nerve as it passes through the carpal tunnel leads to decreased sensation on the palmar aspect of the thumb, index finger, and long finger and on the radial aspect of the ring finger; weakness and atrophy of the muscles in the thenar eminence also occurs. The less frequent entrapment of the ulnar nerve at the wrist causes decreased sensation over the little finger and the ulnar aspect of the ring finger and decreased interosseous muscle strength and mass.

     Elbow:

    Elbow involvement is often detected by palpable synovial proliferation at the radiohumeral joint and is commonly accompanied by a flexion deformity, such as in contractures. Olecranon bursal involvement is common, as are rheumatoid nodules in the bursa and along the extensor surface of the ulna. Nodules are clearly seen in the image Fig NO.26.
     Shoulders:

    Rheumatoid arthritis commonly involves the shoulders and is manifested by tenderness, nocturnal pain, and limited motion. Initially, swelling occurs anteriorly, but it may be difficult to detect and is present on examination in a minority of patients at any point in time. Rotator cuff degeneration secondary to synovitis may limit abduction and rotation. Superolateral migration of the humerus occurs with complete tears. Glenohumeral damage leads to pain with motion and at rest and typically leads to severely restricted motion or “frozen shoulder syndrome.” Acromioclavicular arthritis is not as frequent or as disabling as the other manifestations of this disease.

     Feet and ankles:

    The ankle joint itself is rarely involved without midfoot or MTP involvement. The ankle does not often deform, as it is a mortise joint. Major structural changes occur in the midfoot and foot due to the combination of chronic synovitis and weight bearing. Posterior tibialis tendon involvement or rupture may lead to subtalar subluxation, which results in eversion and migration of the talus laterally. Midfoot disease leads to loss of normal arch contour with flattening of the feet.

    The MTP joints are inflamed in most patients and, due to the heavy loads they bear, commonly become deformed over time. The great toe typically develops hallux valgus (a bunion); subluxation of the phalanx at the MTP joint of the other toes predominantly occurs dorsally. The toes may exhibit compensatory flexion due to a fixed length of the flexor tendons, thus resulting in hammer toes (thought to look like piano hammers). The second and third metatarsal heads commonly protrude and may become the primary weight-bearing surface at the MTP joints. Calluses and pain upon weight bearing result.

     Knees:

    Rheumatoid arthritic knees may develop large effusions and abundant accumulation of synovium. Knee effusions and synovial thickening are common and are easily detected during the early course of the disease. Persistent effusions may lead to inhibition of quadriceps function by spinal reflexes, resulting in subsequent atrophy. Instability may develop after progressive loss of cartilage and weakening of ligaments; deformity may include genu valgus or varus and flexion deformities. The energy expenditure to stand or walk significantly increases if there are flexion deformities of the knees.

     Hips:

    The hips are commonly involved in rheumatoid arthritis; however, because of their deep location, their involvement is not always readily apparent early on during the course of the disease. Hips are difficult to examine by direct inspection or palpation. Limited motion or pain on motion and weight bearing are the hallmarks of hip involvement. The Patrick maneuver (flexion, external rotation, and abduction) is abnormal in this situation. A flexion deformity may be demonstrable by conducting a Thomas test, which is performed by flexing one hip (with the patient supine) while restricting pelvic motion by keeping the other hip in the neutral position on the examination table. If the hip cannot be maintained in the neutral position, a contracture is present.

     Cervical spine:

    Neck pain on motion and occipital headache are common manifestations of cervical spine involvement (see the image Fig NO.10). Most patients with cervical spine involvement have a history of the disease for more than 10 years. Clinical manifestations of early cervical spine disease consist primarily of neck stiffness that is perceived throughout the entire arc of motion. The atlantoaxial joint is a synovial-lined joint and is susceptible to the same proliferative synovitis and subsequent instability seen in the peripheral joints. Patients with severe destruction in the hands (arthritis mutilans) are very likely to have symptomatic cervical spine abnormalities, as are those patients taking significant amounts of corticosteroids for control of rheumatoid arthritis.
    Neurologic involvement ranges from radicular pain to a variety of spinal cord lesions that may result in weakness (including quadriparesis), sphincter dysfunction, sensory deficits, and pathologic reflexes. Transient ischemic attacks (TIAs) and cerebellar signs may reflect vertebral artery impingement from cervical subluxation or basilar artery impingement from upward migration of the dens. Tenosynovitis of the transverse ligament of C1 may lead to C1-C2 instability. Myelopathy secondary to rupture of the transverse ligament may lead to neurologic deficits. Radiculopathy is most common at the C2 root, although symptomatic subluxations may occur at any level.

    Symptoms of cervical myelopathy are gradual in onset and are often unrelated to either the development of or accentuation in neck pain. When neck pain does occur, it frequently radiates over the occiput region in the distribution of the C1-3 nerve roots. The Lhermitte sign, in which tingling paresthesia that descends through the thoracolumbar spine occurs as the cervical spine is flexed, is typically observed.
    During the physical examination, it is important to assess the following signs and symptoms:
    • Stiffness
    • Tenderness
    • Pain on motion
    • Swelling
    • Deformity
    • Limitation of motion
    • Extra-articular manifestations
    • Rheumatoid nodules

    Genetic and environmental factors play a role in pathogenesis. Although laboratory testing and imaging studies can help confirm the diagnosis and track disease progress, rheumatoid arthritis primarily is a clinical diagnosis and no single laboratory test is diagnostic. Complications of rheumatoid arthritis may begin to develop within months of presentation; therefore, early referral to or consultation with a rheumatologist for initiation of treatment with disease-modifying antirheumatic drugs is recommended.

    Several promising new disease-modifying drugs recently have become available, including leflunomide, tumor necrosis factor inhibitors, and anakinra. Nonsteroidal anti-inflammatory drugs, corticosteroids, and nonpharmacologic modalities also are useful. Patients who do not respond well to a single disease-modifying drug may be candidates for combination therapy. Rheumatoid arthritis is a lifelong disease, although patients can go into remission. Physicians must be aware of common comorbidities. Progression of rheumatoid arthritis is monitored according to American College of Rheumatology criteria based on changes in specific symptoms and laboratory findings. Predictors of poor outcomes in early stages of rheumatoid arthritis include low functional score early in the disease, lower socioeconomic status, early involvement of many joints, high erythrocyte sedimentation rate or Creactive protein level at disease onset, positive rheumatoid factor, and early radiologic changes.

    Rheumatoid arthritis is characterized by persistent joint synovial tissue inflammation. Over time, bone erosion, destruction of cartilage, and complete loss of joint integrity can occur. Eventually, multiple organ systems may be affected.

    4.1.2 Imaging:
    X-rays of the hands and feet are generally performed in people with a polyarthritis. In rheumatoid arthritis, there may be no changes in the early stages of the disease, or the X-ray may demonstrate juxta-articular osteopenia, soft tissue swelling and loss of joint space. As the disease advances, there may be bony erosion and subluxation X-rays of other joints may be taken if symptoms of pain swelling occur in those joints. Other medical imaging techniques such as magnetic resonance imaging (MRI) and ultrasound are also used in rheumatoid arthritis.

    There have been technical advances in ultrasonography.High-frequency transducers (10MHz or higher) have improved the spatial resolution of ultrasound images, these images can depict 20% more erosions than conventional radiography. Also, color Doppler and power Doppler ultrasound, which show vascular signals of active synovitis depending on the degree of inflammation, are useful in assessing synovial inflammation. This is important, since in the early stages of rheumatoid arthritis, the synovium is primarily affected, and synovitis seems to be the best predictive marker of future joint damage.

    4.1.3 BLOOD TESTS
    When RA is clinically suspected, immunological studies are required, such as testing for the presence of rheumatoid factor (RF, a non-specific antibody). negative RF does not rule out RA; rather, the arthritis is called seronegative.
    This is the case in about 15% of patients. During the first year of illness, rheumatoid factor is more likely to be negative with some individuals converting to seropositive status over time.RF is also seen in other illnesses, for example Sjogren’s syndrome, Hepatitis C,chronic infections and in approximately 10% of the healthy population and therefore the test is not very specific.
    Because of this low specificity, new serological tests have been
    developed, which test for the presence of anticitrullinated protein antibodies
    (ACPAs) or anti-CCP.Like Rf, these tests are positive in only a proportion
    (67%) of all R A cases, but are rarely positive if RA is not present, giving it a
    specificity of around 95%.As with RF, there is evidence for ACP as being
    present in many cases even before onset of clinical disease.

    The most common tests for ACP As are the anti-CCP (cycliccitrullinated peptide) test and the Anti-MCV assay (antibodies against mutated citrullinated Vimentin).Recently a serological point-of-care test (POCT) for the early detection of RA has been developed. This assay combines the detection of rheumatoid factor and anti-MCV for diagnosis of rheumatoid arthritis and shows a sensitivity of 72% and specificity of 99.7%.
    Also, several other blood tests are usually done to allow for other causes of arthritis, such as lupus erythematosus. The erythrocyte (the sedimentation rate (ESR), C-reactive protein, full blood count, renal function, liver enzymes and other immunological tests (e.g., antinuclear antibody/ANA) are all performed at this stage. Elevated ferritin levels can reveal hemochromatosis, a mimic RA, or be assign of Still’s disease a seronegative, usually juvenile, variant of rheumatoid.

    Laboratory and Imaging Findings Associated with Rheumatoid Arthritis

    Creactive protein* Typically increased to >0.7 picograms per mL; may be used to monitor disease course.
    Erythrocyte sedimentation rate* Often increased to >30 mm per hour; may be used to monitor disease course.
    Hemoglobin/hematocrit* Slightly decreased; hemoglobin averages around 10 g per dL (100 g per L); normochromic anemia, also may be normocytic or microcytic.
    Liver function* Normal or slightly elevated alkaline phosphatase
    Platelets* Usually increased
    Radiographic findings of involved joints* May be normal or show osteopenia or erosions near joint spaces in early disease; wrist and ankle films are useful as baselines for comparison with future studies.
    Rheumatoid factor* Negative in 30 percent of patients early in illness; if initially negative, can repeat six to 12 months after disease onset; can be positive in numerous other processes (e.g., lupus; scleroderma; Sjögren’s syndrome; neoplastic disease; sarcoidosis; various viral, parasitic, or bacterial infections); not an accurate measure of disease progression.
    White blood count* May be increased
    Anticyclic citrullinated peptide antibody Tends to correlate well with disease progression; increases sensitivity when used in combination with rheumatoid factor; more specific than rheumatoid factor (90 versus 80 percent); not readily available in many laboratories.
    Antinuclear antibody Limited value as a screening study for rheumatoid arthritis
    Complement levels Normal or elevated
    Immunoglobulins Elevated alpha-1 and alpha-2 globulins possible.
    Joint fluid evaluation Consider if an affected joint can be tapped and diagnosis is uncertain; straw-colored fluid with fibrin flecks often seen; fluid may clot at room temperature; 5,000 to 25,000 white blood cells per mm3 (5 to 25 × 109 per L) with 85 percent polymorphonuclear leukocytes a common finding; in rheumatoid arthritis, cultures are negative, there are no crystals, and fluid glucose level typically is low.
    Urinalysis Microscopic hematuria or proteinuria may be present in many connective tissue diseases.

    *—Recommended for initial evaluation for rheumatoid arthritis.
    note: Renal function, although not as likely to change as a direct effect of disease, should be followed to assess renal effects of drug therapy.

    CHAPTER- 5

    In 2010 the 2010 ACR/EULAR Rheumatoid Arthritis Classification Criteria were introduced. These new classification criteria overruled the “old” ACR criteria of 1987 and are adapted for early RA diagnosis. The “new” classification criteria jointly published by the American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) establish a point value between 0 and 10.every patient with a point total of 6 or higher is unequivocally classified as an RA patient, provided he has synovitis in at least one joint and given that there is no other diagnosis better explaining the synovitis.Four areas are covered in the diagnosis.
    Joint involvement, designating the metacarpophalangeal joints, proximal interphalangeal joints, the interphalangeal joint of the thumb, second through third metatarsophalangeal joint and wrist as small joints, and elbows, hip joints and knees as large joints;
     Involvement of 2-10 large joints gives 1point
     Involvement of 1-3 small joints (with or without involvement of large joints) gives
     points
     Involvement of 4-10 small joints (with or without involvement of large joints) gives
     points
     Involvement of more than 10 joints (with involvement of at least 1 small joint) gives
    5 points.
    Serological Parameters-including the rheumatoid factor as well as ACPA- “ACPA”stand for “anti-citrullinated protein antibody”
     Negative RF and negative ACPA gives 0 points
     Low-positive RF or low-positive ACPA gives 2 points
     High-positive RF or high-positive ACPA gives 3 points
     Acute phase reactants:1 point for elevated erythrocyte sedimentation rate,ESR,or CRP value (c-reactive protein).
     Duration of arthritis: 1 point for symptoms lasting six weeks or longer.
    The new criteria accommodate to the growing understanding of rheumatoid arthritis and the improvement in diagnosing RA and disease treatment. In the “new” criteria serology and autoimmune diagnostics carries major weight, as ACPA detection is appropriate to diagnose the disease in an early state, before joints destructions occur. Destruction of the joints viewed in radiological images was a significant point of the ACR criteria from 1987. This criterion no longer is regarded to be relevant, as this is just the type of damage that treatment is meant to avoid.
    The criteria are not intended for the diagnosis for routine clinical care; they were primarily intended to categorize research (classification criteria).In clinical practice, the following criteria apply:
    o Two or more swollen joints
    o Morning stiffness lasting more than one hour for at least six weeks
    o The detection of rheumatoid factors or autoantibodies against ACPA such as autoantibodies to mutated citrullinated vimentin can confirm the suspicion of rheumatoid arthritis. A negative autoantibody result does not exclude a diagnosis of RA.

    Revised American Rheumatism Association Criteria for Classification of Rheumatoid Arthritis

    Percentage with rheumatoid arthritis if sign or symptom is*:
    Sign or symptom Definition LR+ LR- Present Absent
    Morning stiffness Stiffness in or around the affected 1.9 0.5 39 14
    joints for at least one hour after initiating movement
    Arthritis of three or more joint areas Three or more of the following joints noted to be fluid-filled or have soft tissue swelling: wrist, PIP, MCP, elbow, knee, ankle, MTP 1.4 0.5 32 13
    Hand joint involvement Wrist, MCP, or PIP joints among the symptomatic joints observed 1.5 0.4 33 12
    Symmetric arthritis Right and left joints involved for one or more of following: wrist, PIP, MCP, elbow, knee, ankle, MTP† 1.2 0.6 29 17
    Rheumatoid nodules Subcutaneous nodules in regions surrounding joints, extensor surfaces, or bony prominences 3.0 0.98 50 25
    Serum rheumatoid factor positive Positive result using any laboratory test that has a positive predictive value of 95 percent or more (i.e., is positive in no more than 5 percent of patients without rheumatoid arthritis) 8.4 0.4 74 13
    Radiographic changes Hand and wrist films show typical changes of erosions or loss of density adjacent to affected joints 11 0.8 79 21

    *—Assumes overall probability of rheumatoid arthritis of 30 percent.
    †—PIP, MCP, and MTP joints need not be absolutely symmetrical.
    LR+ = positive likelihood ratio; LR-= negative likelihood ratio; PIP= proximal interphalangeal; MCP= metacarpophalangeal; MTP= metatarsophalangeal.

    5.2 Types Of Rheumatoid Arthritis:
    Rheumatoid arthritis is an autoimmune, progressive disease in which the immunity of our body is confused and starts attacking our own healthy tissues. The disease mainly affects joints. But it can also affect ligaments, tendons, and other systemic organs. There are various types of rheumatoid arthritis.Juvenile Rheumatoid Arthritis is the RA occurring in children below the age of 16. In this too, there are three types, viz. polyarticular, pauciarticular and systemic juvenile rheumatoid arthritis. In polyarticular JRA, five or more joints are affected. It is one of the most dangerous types of rheumatoid arthritis and needs to be controlled as soon as possible by aggressive treatment. Pauciarticular JRA or oligoarthritis attacks four or less joints and occurs more in girls than in bo

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