Homoeopathic Approach To Osteoarthritis
NATIONAL JOURNAL OF HOMOEOPATHY 2003 Jul / Aug VOL V NO 4.
Dr Anand Kapse
Dr Anagha Phanse
Dr Sonali Datey
'Kali-c / Calc-fl / Sil

Introduction:
Osteoarthritis is a fairly common disease prevalent in the community. This article aims to discuss the basic clinico-pathological knowledge relating to OA and its importance for a Homoeopath. The article will try to demonstrate the importance of Susceptibility, Sensitivity and Miasm in Homoeopathic treatment of OA with the help of illustrative cases.
[Editor: The authors had submitted an exhaustive write up for the General aspects, which has not been published as it has covered elsewhere in the issue, in the General section.]

Origins of joint pain in pts with OA

While undertaking study on osteoarthritis two features struck the most
1. A revelation that OA should not be viewed simply as a disease/failure of single tissue-the cartilage, but of an organ-the diarthrodial joint
2. The pain does not originate from articular cartilage as it is aneural. Hence, it must originate from other structures in the joint.
The tissues involved and the mechanisms of pain are as under

Tissue	Mechanism of pain
1. Subchondral bone	Medullary hypertension, micro fractures
2. Osteophytes	Stretching of nerve ending in periosteum
3. Ligaments	Strech
4. Enthesis	Inflammation
5. Joint capsule	Inflammation, distension
6. Periarticular muscle	Spasm
7. Synovium	Inflammation

Finer knowledge of the tissue involved and the mechanisms of pain can improve our therapeutic approach especially in defining the sector remedy for a specific case. Patients describe different types of pains which could be helpful to understand the tissue affected. Prospective studies are required in this area. Such studies can bring about a revolution in our therapeutic management of osteoarthritis.
The joint pain in patients with OA may arise from periarticular as well as articular structures. It is common for the patient with OA to develop soft tissue rheumatism in areas adjacent to the involved joint, for eg: Anserine bursitis in patient with knee OA, trochanteric bursitis in patient with hip OA.

Diagnosis of OA

The diagnosis of OA is usually based on clinical and radiographic features. In the early stages X-ray may be normal, but as articular cartilage is lost, narrowing of the joint space becomes evident. Other characteristic X-ray findings include subchondral cysts, subchondral sclerosis and marginal osteophytes.
A Knee X-ray in standing position exhibits joint space narrowing more accurately in the supine position. Therefore the antero-posterior (AP) view is taken in standing position.
Synovial fluid analysis is not usually done in patients with OA.

Ancillary measures
Exercise forms an integral part in the management of OA. The goals of an exercise program for the patient with OA should be:

• Reduction of impairment and improvement of function, i.e. reduction of joint pain, increases in Range of Motion (ROM) and strength, normalization of gait and improvement in performance of daily activities.
• Protection of the OA joint from further damage by reducing stress on the joint, attenuating joint forces and improving biomechanics
• Prevention of disability and poor health secondary to inactivity by increasing the daily level of physical activity and improving physical fitness.

For knee OA, a combination of exercises including ROM, strengthening and low-impact aerobic exercises is appropriate. Aerobic exercises that may be recommended include-walking, biking, swimming, aerobic- dance, aerobic pool exercises.
Patients generally tolerate walking without an increase in symptoms, if they begin slowly and gradually increase their walking time. Walking regularly with dietary regulation also helps in weight reduction in obese subjects, which in turn may result in a reduction in pain and improvement in function of joints.

Thermal modalities viz. application of heat, cold or both offer short term pain relief. Heat may be applied as superficial and deep heat. Diathermy employed as either shortwave or microwave and ultrasound are the three forms of deep heat. Cold may be delivered by icepacks, ice massage and local sprays.
Proper footwear eg wedged insoles may be useful in the conservative treatment of OA in the medial tibio-femoral compartment.
For effective management of many patients with OA encouragement, reassurance, advice about exercise and recommendation of measures to unload the arthritic joint such as a cane and proper footwear are required along with the therapeutic intervention.

CLINICAL EXPERIENCES
Now we will take up study of some representative cases and then try to derive some general conclusions.

CASE 1
Mrs PS, 48, housewife, Education FYBA
Chief Complaints

Location	Sens and Comp	Modality	Accompainment
KNEE Rt to Lt Ankle Calf Since 5-6 months	PAIN Stiffness Numbness swelling	< Night < Sitting < Crossing legs < Squatting > Warm Water > Pressure	sleep disturbed

INVESTIGATIONS
X-ray Lt knee joint - osteophyte formation, degenerative changes. Joint space normal.
X-ray Rt knee joint-(1997) osteophyte formation, degenerative changes. Joint space normal.

PLANNING ANd PROGRAMMING
Susceptibility-High. Sensitivity-Moderate. Phase-Early structural
Dominant Miasm-Sycosis.
Fundamental Miasm-Syphilis

FOLLOW UP
The patient was given a single dose of Kali-carb 200 on 22^nd November 2000. There was total relief in all the complaints for 6 months. After 6 months the knee pains reappeared due to a fall. This time (May 01) she needed Kali-carb 200 3P weekly for a few weeks along with occasional doses of Thuja 200. Patient has not required any medicines since September 01.

CASE 2
Preliminary Information
Mrs MR, 51; Education MA (Eng) BEd
Occupation- Teacher.
Husband- Principal project director in a thermal power station
Daughters: 2, Brothers: 2, Sisters: 2
Father: dead Mother: alive
CHIEF COMPLAINT
Bilateral knee joint pain; piercing type+++ (RightàLeft) since 6 yrs with stiffness ++, Swelling ++. Limps while walking. <Anxiety, Worries > Hot Fomentation
Backache On & Off < Exertion
O/E-Bilateral knee tenderness ++. Crepitus++. Swelling.
Weight-83 kg, B.P.- 150/90 mmHg
X-Ray - Osteophytes with joint space reduction.
BMD - Osteopenia spine, femur NAD.

DIAGNOSIS - Osteoarthritis knee.
P/H - Childhood Asthma,
Uterine fibroid-Hysterectomy done.
F/H - Diabetes (Father).
Hypertension, Osteoarthritis (Mother)

REMEDY SELECTION
Patient is the wife of principal project director. Handling of such VIP patient in our Palghar Hospital is a bit difficult. Hence, when patient came on the day of appointment, it created kind of a drama. Patient came sharp at the time of appointment with her husband, but the consultant had gone out for some meeting as he was not aware of the appointment. This was enough for her to get angry and behave harshly. The intervention by another senior physician helped to calm down the situation. It was a very difficult task for the junior Physician to convince and answer patient’s questions.
Patient is a fair, obese lady who talked continuously and expressively during interview. She comes from a rich, well-educated and close knit family. Her life since beginning is classy and bossy. Her Father, a dashing and commanding Income Tax commissioner was her role model. It was very clear from her interview, that she has tremendous attachment for her family which leads to anxiety and irritation. She never tolerates anything against her family members. She is very sensitive and weeps immediately for small matters. During interview, she wept when she was narrating about her work. Several times she dominates on others. She has stage fright. As a child, adolescent she had fear of ghost, thieves, and murderers (Had hobby of reading mystery books and watching horror serials). She depends on her husband even for small decisions. She has aspirations to do something different and establish an identity for self. But has no concrete actions in this direction! Anxiety and` worries in her mind increase her knee joint pains.

Characteristic Physicals:
Thermals-C3H2
Obesity, Flabby
Soles cracks <+ winter
Craving-fried³, spicy³,
Aversion-sweets, ice-cream²,
< B. Menses-breast heaviness ++. Pain ++.
Considering all the above data Calc-carb & Kali-carb came up for differentiation.

PLANNING AND PROGRAMMING

• Susceptibility - Moderate
• Sensitivity-High (mind level)
• Phase-Structural Irreversible
• Fundamental Miasm-Syco-Tubercular. (Considering F/H & P/H and physique of the patient )
• Dominant Miasm-Sycosis (Osteoarthritis of knee with essential Hypertension)

FOLLOW UP
Treatment started in Oct 2002, with Calc-carb 200 single dose weekly. It was given for 2 weeks, without any improvement. Patient came with lots of anxiety and irritation. Then again, we studied the whole case plus patient’s behaviour in the hospital till now and gave Kali-carb 200 single dose. Later Thuja 200 was introduced as an intercurrent along with main force. Still initially the improvement was slow. After gradually increasing the repetition of constitutional till QDS patient showed 70-80% improvement. In this case obesity is the main barrier in improvement. Patient did not follow proper dietary restrictions or physiotherapy exercises.

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